i 

m 


THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


PRINCIPLES  AND  PRACTICE 


OF 


MODERN  OTOLOGY 


BY 


JOHN   F.    BARNHILL,    M.  D. 

PROFESSOR  OF  OTOLOGY,  LARYNGOLOGY,  AND  RH1NOLOGY,  INDIANA  UNIVERSITY 

SCHOOL  OF    MEDICINE;    OTOLOGIST  AND  LARYNGOLOGIST  TO 

DEACONESS  AND  STATE  COLLEGE  HOSPITALS,  ETC. 


AND 


ERNEST    deWOLFE    WALES,  B.  S.,    M.  D. 

ASSOCIATE  PROFESSOR  OF  OTOLOGY,  LARYNGOLOGY,  AND  RHINOLOGY,  INDIANA  UNIVERSITY 

SCHOOL  OF  MEDICINE;  FORMER  ASSISTANT  IN  OTOLOGY,  HARVARD  MEDICAL 

SCHOOL  ;  FORMER  ASSISTANT  AURAL  SURGEON,  MASSACHUSETTS 

CHARITABLE  EYE  AND   EAR   INFIRMARY,   ETC. 


WITH  305  ORIGINAL  ILLUSTRATIONS,  MANY  IN  COLORS 


PHILADELPHIA  AND   LONDON 

W.    B.    SAUNDERS    COMPANY 

1907 


Copyright,  1907,  by  W.  B.  Saundera  Company 


£00 


TO  ALL   ENGLISH   SPEAKING  STUDENTS  AND   PRACTITIONERS  OF 
MEDICINE  THIS   VOLUME  IS  DEDICATED   BY   THE  AUTHORS 


PREFACE 


IN  the  preparation  of  this  work,  which  is  intended  for  the  use  of 
students  and  practitioners  of  general  medicine,  among  others  the  fol- 
lowing objects  have  been  kept  in  view: 

1.  To  modernize  the  subject. 

The  methods  of  practice  in  otology  have  changed  so  rapidly  that 
much  concerning  the  subject  which  was  only  recently  accepted  as  a 
standard  of  guidance  is  now  almost  entirely  obsolete.  This  statement 
is  especially  true  of  the  suppurative  affections  of  the  temporal  bone, 
the  treatment  of  which  is  now  based  upon  a  more  thorough  knowledge 
of  the  anatomy  of  this  bone  and  its  environs,  upon  more  accurate  diag- 
nostic methods,  and  upon  more  nearly  correct  medical  and  surgical 
principles. 

The  text  has  been  written  from  the  valued  personal  instruction 
received  from  such  eminent  teachers  as  J.  E.  Sheppard  of  New  York, 
Dundas  Grant  and  Percy  Jakins  of  London,  Jansen  of  Berlin,  and  Alt 
of  Vienna;  from  the  authors'  personal  experience  as  practitioners  and 
teachers ;  from  the  opinions  of  contemporaries  gained  by  active  partici- 
pation in  the  several  American  societies  devoted  to  otology;  and, 
lastly,  from  recent  American  and  European  literature.  Of  the  liter- 
ature, however,  no  attempt  has  been  made  to  give  a  complete  digest. 

2.  To  correct  certain  traditional  beliefs. 

Several  factors  have  greatly  limited  the  progress  of  otology  in  the 
past.  Chief  among  these  are  the  strangely  persistent  beliefs  that  children 
will  outgrow  their  aural  ailments,  and  that  a  discharging  ear  is  nothing 
more  than  an  annoyance,  or  is  even  beneficial  to  the  individual.  Since 
neither  belief  has  any  basis  in  fact,  and  since  abundant  clinical  and 
postmortem  evidence  proves  the  absurdity  of  both,  the  effort  has  been 
made  to  point  out  the  far-reaching  and  harmful  results  of  these 
traditions,  and  in  their  stead— 

3.  To  advocate  the  earliest  possible  prophylaxis  or  treatment. 
While  much,  but  not  too  much,  attention  has  recently  been  given 

to  the  surgical  aspect  of  otology,  certainly  too  little  has  been  paid  to 
the  prevention  of  aural  affections.  Throughout  this  entire  work,  there- 
fore, on  all  proper  occasions,  the  fact  is  stated  that  prevention  of  aural 

7 


8  PREFACE 

diseases  is  usually  easy  in  early  childhood,  whereas  benefit  or  cure  as 
a  result  of  treatment  in  later  life  is  often  impossible. 

4.  To  emphasize  the  importance  of  a  thorough  examination  and  a 
definite  diagnosis  as  a  basis  for  rational  treatment. 

Empiricism  in  both  diagnosis  and  treatment  have  heretofore  played 
too  large  a  part  in  the  practice  of  otology.  Since  success  in  the  practice 
of  this  branch  of  medicine  depends  almost  wholly  upon  correct  diagnosis, 
the  methods  of  investigation  into  the  nature  of  aural  diseases  are  given 
in  detail,  and  their  practice  is  insisted  upon  in  every  case,  however 
simple  it  may  appear. 

5.  To  thoroughly  illustrate  the  text. 

The  preparation  of  the  illustrations  has  been  given  the  greatest 
care.  A  large  number  of  the  drawings  have  been  made  by  Mr.  H.  F. 
Aitken, — some  directly  from  the  anatomic  specimen  and  others  from 
the  actual  patient  during  the  progress  of  an  examination,  treatment, 
or  surgical  operation, — a  few  are  schematic,  and  only  a  very  few  have 
been  copied.  The  instruments  shown  are  those  in  daily  use  by  the 
authors.  Therefore,  some  are  bent  and  apparently  misshapen, — a  form 
necessary  in  actual  practice  to  meet  the  requirements  of  some  indi- 
vidual case.  While,  therefore,  they  do  not  have  that  stiff  and  precise 
shape  of  the  mechanical  drawings  usually  shown  in  works  on  otology,  it 
is  believed  that  the  illustrations  of  tools  that  have  been  taken  directly 
from  active  service  are  better  suited  to  a  practical  work  of  this  kind. 

Thanks  are  due  to  Mr.  H.  F.  Aitken  for  his  faithful  and  painstaking 
work  in  illustration;  to  Harvard  University  for  the  loan  of  the  several 
most  excellent  specimens  showing  the  ravages  of  suppurative  necrosis 
of  the  temporal  bone,  and  to  Mr.  Willard  C.  Greene  who  faithfully 
photographed  the  same;  to  Mr.  John  Nicholson  and  the  Stafford 
Engraving  Company,  who  executed  the  photography  and  art  work 
in  the  representation  of  many  subjects  and  instruments;  to  Dr.  Paul 
B.  Coble,  who  has  read  the  proof;  and,  lastly,  to  the  publishers  upon 
whom  devolved  the  final  task  of  producing  a  masterpiece  in  book- 
making. 

The  first  three  chapters  and  the  pathology  have  been  prepared  by 
Dr.  Wales;  the  balance  of  the  work  by  Dr.  Barnhill. 

INDIANAPOLIS,  October,  1907. 


CONTENTS 


CHAPTER  I 

PAGES 

ANATOMY  OF  THE  TEMPORAL  BONE 17-62 

Introduction — Position  of  the  Temporal  Bone  in  the  Skull — The 
Squamous  Portion  of  the  Temporal  Bone — The  Tympanic  Bone — The 
Petrous  Bone — Mastoid  Process — Pneumatic  Cells  in  the  Temporal 
Bone  of  the  Infant — The  Petrous  Bone — The  Cerebellar  Surface  of 
the  Petrous  Bone — The  Facial  or  Fallopian  Canal — The  Jugular 
Surface  or  Inferior  Posterior  Surface — The  Tympanomastoid  or 
Anterior  Inferior  Wall  of  the  Petrous  Bone — The  Infant  Temporal 
Bone — The  Auricle — The  External  Osseous  Canal — The  Drum  Mem- 
brane— -The  Ossicles — The  Eustachian  Tube — The  Osseous  Laby- 
rinth— The  Vestibule — The  Cochlea — Membranous  Labyrinth — 
Anatomy. 

CHAPTER  II 
PHYSIOLOGY  OF  THE  ORGAN  OF  HEARING 63-68 

The  Tensor  Tympani  Muscle — Stapedius  Muscle — Semicircular 
Canals — Vestibule  —  Cochlea  —  Drum  Membrane — Auricle — Conduc- 
tion of  Sound-waves — The  Function  of  the  Intrinsic  Muscles  of  the 
Ear— The  Organ  of  Corti. 

CHAPTER  III 

BACTERIOLOGY  OF  THE  EAR 69-78 

Investigation  of  Aural  Discharges — Scarlet  Fever — Scarlet  Fever  with 
Diphtheria  —  Measles  —  Diphtheria  —  Typhoid  Fever  —  Cerebrospinal 
Meningitis — Gonococcus — Otitis  Media — Otitis  of  Infants — Complica- 
tions of  the  Middle-Ear  Inflammation — Conclusions. 

CHAPTER  IV 

THE  CAUSATION  OF  EAR  DISEASES 79-83 

Loud  Noises — Cold  and  Heat — Foreign  Bodies — Injuries  from  Falls 
or  Blows — General  Diseases  as  Causative  Agents — Causes  that  Act 
through  the  Nasopharynx  and  Eustachian  Tube. 

CHAPTER  V 

DISEASES  OF  THE  EXTERNAL  EAR 84-90 

Malformation  of  the  Auricle — Undeveloped  Helix — Absence  of  Lobule — 
Cartilaginous  Projections — Microtia  and  Entire  Absence  of  the  Auri- 
cle— Supernumerary  Auricles — Polyotia — Congenital  Fistulas. 

9 


IO  CONTENTS 

CHAPTER  VI 


PACES 


DISEASES  OF  THE  AURICULAR  PERICHONDRIUM 91-95 

Perichondritis — Symptoms,  Treatment. 
Othematoma — Symptoms,  Diagnosis,  Treatment. 

CHAPTER  VII 

TUMORS  OF  THE  AURICLE 96-103 

Benign  Tumors — 

Sebaceous  Cysts — Treatment. 

Fibroma — Prognosis,  Treatment. 

Papilloma — Treatment. 

Angiomata — Treatment. 
Malignant  Tumors — 

Sarcomata — Diagnosis,  Treatment. 

Epithelioma — Treatment. 

CHAPTER  VIII 

CUTANEOUS  AFFECTIONS  OF  THE  EXTERNAL  EAR 104-120 

Eczema — • 

The  Acute  Form — Causation,  Symptoms,  Prognosis,  Treatment. 

Chronic  Eczema — Treatment. 
Noma — Diagnosis. 
Lupus  of  the  Ear — 

Lupus  Erythematosus — Symptoms,  Diagnosis,  Treatment. 

Lupus    Vulgaris — Causation,    Symptoms,    Diagnosis,    Prognosis, 

Treatment. 
Herpes  Zoster — Causation,  Symptoms,  Treatment. 

CHAPTER  IX 

ACUTE  CIRCUMSCRIBED  AND  ACUTE  DIFFUSE  INFLAMMATION  OF  THE 

EXTERNAL  AUDITORY  MEATUS 121-132 

Otitis  Externa  Circumscripta — 

Furuncle — Causation,   Symptoms,    Diagnosis,   Differential    Diag- 
nosis, Treatment. 
Diffuse  Inflammation  of  the  External  Auditory  Meatus — 

Otitis  Externa  Diffusa — Causation,  Symptoms,  Differential  Diag- 
nosis, Prognosis,  Treatment. 

CHAPTER  X 

CROUPOUS  AND  DIPHTHERITIC  INFLAMMATION  OF  THE  EXTERNAL 

AUDITORY  MEATUS I33~i3S 

Croupous  Inflammation — Cause,  Treatment. 
Diphtheritic  Inflammation — Treatment. 

CHAPTER  XI 

PARASITIC  INFLAMMATION  OF  THE  EXTERNAL  AUDITORY  CANAL — 

FUNGOID  OTITIS  EXTERNA — OTOMYCOSIS 136-138 

Causation,  Diagnosis,  Treatment. 


CONTENTS 

CHAPTER  XII 

PAGES 

FOREIGN  BODIES  IN  THE  EXTERNAL  AUDITORY  MEATUS 139-146 

Symptoms,  Diagnosis,  Prognosis,  Treatment. 

CHAPTER  XIII 

IMPACTED  CERUMEN 147-151 

Symptoms,  Diagnosis,  Prognosis,  Treatment. 

CHAPTER  XIV 

EXOSTOSES  OF  THE  EXTERNAL  AUDITORY   MEATUS 152-156 

Symptoms,  Physical  Examination,  Prognosis,  Treatment. 

CHAPTER  XV 

CARIES  OF  THE  WALLS  OF  THE  EXTERNAL  OSSEOUS  MEATUS  \VITH 
FISTULA  LEADING  INTO  SOME  PORTION  OF  THE  ADJOIN- 
ING TEMPORAL  BONE 157-158 

Causes  and  Treatment. 

CHAPTER  XVI 

OTHER  CONDITIONS  OF  THE  EXTERNAL  AUDITORY  MEATUS  THAT 

ARE  MORE  RARELY  ENCOUNTERED 159-163 

Hemorrhagic  External  Otitis — Symptoms,  Diagnosis,  Treatment. 

Spontaneous  Hemorrhage  from  the  Auditory  Meatus. 

Syphilis  of  the  Auditory  Meatus — Treatment. 

Vicarious  Hemorrhage  of  the  Ears. 

Traumatic  Hemorrhage  from  the  Auditory  Canal. 

Ear  Cough. 

CHAPTER  XVII 

THE  METHODS  OF  THE  EXAMINATION  OF  THE  PATIENT 164-192 

The  Physical  Examination. 

The  Light  and  its  Employment. 

Aural  Specula,  their  Selection  and  Methods  of  Use. 

Retraction  of  the  Auricle. 

The  Membrana  Tympani. 

Normal  Drum-head. 

The  Diseased  Tympanic  Membrane. 
Impediments  to  the  Examination  of  the  External  Auditory  Canal  and 

Fundus  of  the  Ear. 
Determination  of  the  Patency  of  the  Eustachian  Tube  and  the  Method 

of  Inflation  of  the  Middle  Ear. 
Valsalva  Method. 
The  Politzer  Method. 

Technic  of  Politzerization. 
Catheterization  of  the  Eustachian  Tube. 

Technic  of  Eustachian  Catheterization. 

First,  Second,  and  Third  Methods. 

Difficulties  Sometimes  Encountered  during  Catheterization. 
Aural  Auscultation. 
Fatal  Results  from  Catheterization. 


12  CONTENTS 

CHAPTER  XVIII 

PAGES 

EXAMINATION  OF  THE  FUNCTION  OF  THE  EAR 193-201 

The  Watch  Test,  The  Voice  Test,  Politzer's  Acumeter,  Tuning-fork, 

The  Schwabach  Test,  Weber's  Test,  Rinne's  Test. 
Summary  of  the  Various  Tuning-fork  Tests  and  of  the  Interpretation  of 

the  Results  Obtained  from  Each,  or  from  All  Used  Collectively. 

CHAPTER  XIX 

THE  INFLUENCE  OF  NASAL  AND  NASOPHARYNGEAL  DISEASES  UPON 

AFFECTIONS  OF  THE  EAR 202-222 

Adenoids — Diagnosis,  Treatment. 

ACUTE  AFFECTIONS  OF  THE  MIDDLE  EAR 223 

Preliminary  Remarks. 

CHAPTER  XX 

DISEASES  AND  INJURIES  OF  THE  MEMBRANA  TYMPANI 223-234 

Acute  Myringitis — Symptoms,  Diagnosis,  Treatment. 

Chronic  Myringitis — Symptoms,  Treatment. 

Injuries  to  the  Membrana  Tympani — Symptoms,  Treatment. 

CHAPTER  XXI 

ACUTE  TUBOTYMPANIC  CATARRH. 235-249 

Causation,   Pathology,   Symptoms,   Diagnosis,   Prognosis,   Treatment. 

CHAPTER  XXII 
ACUTE  CATARRHAL  OTITIS  MEDIA 250-262 

Causation,  Symptoms,  Prognosis,  Treatment. 

CHAPTER  XXIII 

ACUTE  SUPPURATIVE  OTITIS  MEDIA 263-277 

Causation,  Pathology,  Symptoms,  Prognosis,  Treatment. 
Differential  Diagnosis  of  Acute  Tubotympanic  Catarrh,  Acute  Catarrhal 
Otitis  Media,  and  Acute  Suppurative  Otitis  Media. 

CHAPTER  XXIV 

ACUTE  MASTOIDITIS 278-289 

Causation. 

Diagnosis — The  Physical  Condition  of  the  Patient,  the  External  Mani- 
festations over  the  Mastoid  Region,  Changes  at  Inner  End  of  Audi- 
tory Canal,  Membrana  Tympani,  and  in  the  Middle  Ear. 

Prognosis,  Treatment. 


CONTENTS  13 

CHAPTER  XXV 

PAGES 

THE  MASTOID  OPERATION  FOR  ACUTE  MASTOIDITIS 290-320 

Preparation  of  the  Patient.     The  Operation. 

The  Landmarks  upon  the  Mastoid  Portion  of  the  Temporal  Bone 

which  are  Exposed  by  the  Primary  Incisions. 
Opening  the  Mastoid  Antrum. 
Bezold's  Abscess — Subperiosteal  Abscess. 
Mastoiditis  in  Infants — Causation,  Symptoms,  Diagnosis. 
The  Mastoid  Operation  on  Children  under  Two  Years  of  Age. 

CHAPTER  XXVI 
CHRONIC  PURULENT  OTITIS  MEDIA 321-338 

Causes,  Pathology,  Symptoms,  and  Diagnosis. 

CHAPTER  XXVII 

CHRONIC  PURULENT  OTITIS  MEDIA  (Continued) 339~352 

The    Medicinal    Treatment — Constitutional    Treatment;    Nasal    and 

Nasopharyngeal  Management;  Local  Medication. 
Mechanical  Removal  of  Accumulated  Septic  Matter. 
Methods  of  Drying  the  Parts — Cotton  Cylinder;  Heated  Air;  Drying 

Powders;  The  Gauze  Wick. 
Ear  Drops,  Caustics,  Cocain  Anesthesia. 

CHAPTER  XXVIII 

CHRONIC  PURULENT  OTITIS  MEDIA  (Continued) 353-364 

The  Surgical  Treatment.     Intratympanic  Surgery. 
Removal  of  Polypi  by  Curet  or  Snare. 

Ossiculectomy  and  Curetage  of  the  Middle  Ear  and  Attic  in  the  Treat- 
ment of  Chronic  Suppurative  Aural  Diseases. 

CHAPTER  XXIX 
CHRONIC  MASTOIDITIS 365-374 

Causation,  Pathology,  Symptoms,  and  Diagnosis. 

CHAPTER  XXX 

CHRONIC  MASTOIDITIS  (Continued) 375-408 

Treatment — The  Radical  Mastoid  Operation — Preliminary  Remarks. 

Indications  for  the  Performance  of  the  Radical  Mastoid  Operation. 

Technic  of  the  Radical  Mastoid  Operation. 

Method  of  Making  the  Kbrner  Flap — The  Panse  Flaps — Skin  Grafting. 

Technic  of  Skin  Grafting. 

Accidents  and  Dangers  that  may  occur  during  the  Performance  of  or 

Subsequent  to  the  Radical  Mastoid  Operation. 
Facial  paralysis — The  Surgery  of  the  Facial  Nerve,  Results. 


14  CONTENTS 

CHAPTER  XXXI 

PAGES 

THE  INTRACRANIAL  COMPLICATIONS  OF  SUPPURATIVE  PROCESSES 

WITHIN  THE  TEMPORAL  BONE 409-414 

General  Considerations — Frequency. 

CHAPTER  XXXII 
INTRACRANIAL  COMPLICATIONS  (Continued} 415-423 

Sinus  Phlebitis  and  Sinus  Thrombosis. 

Pathology,  Diagnosis,  and  Symptoms — Atypic  Cases. 

CHAPTER  XXXIII 
INTRACRANIAL  COMPLICATIONS  (Continued) 424-435 

Treatment  of  Sinus  Infection  and  Sinus  Thrombosis. 
Technic  of  the  Ligation  of  the  Internal  Jugular  Vein. 

CHAPTER  XXXIV 
INTRACRANIAL  COMPLICATIONS  (Continued) 436-444 

Otitic  Brain  Abscess — Pathology,  Symptoms,  Diagnosis,  Prognosis. 

CHAPTER  XXXV 
INTRACRANIAL  COMPLICATIONS  (Continued) 445-455 

The  Treatment  of  Brain  Abscess — Surgical  Treatment  of  Extradural 

Abscess. 
Treatment  of  Temporosphenoidal  Abscess. 

CHAPTER  XXXVI 
INTRACRANIAL  COMPLICATIONS  (Continued} 456-461 

Cerebellar  Abscess — Symptoms,  Diagnosis,  Treatment. 

CHAPTER  XXXVII 

INTRACRANIAL  COMPLICATIONS  (Continued) 462-469 

Infective    Meningitis — Symptoms,   Diagnosis,   Differential    Diagnosis, 
Prognosis,  Treatment. 

CHAPTER  XXXVIII 

SUPPURATION  AND  NECROSIS  OF  THE  TEMPORAL  BONE  AND  ITS 

PRACTICAL  RELATION  TO  LIFE  INSURANCE 470-474 

CHAPTER  XXXIX 

CHRONIC  NON-SUPPURATIVE  OTITIS  MEDIA 475-489 

Preliminary  Remarks — Causation,  Symptoms,  Prognosis. 


CONTENTS  15 

CHAPTER  XL 

PAGES 

CHRONIC  NON-SUPPURATIVE  OTITIS  MEDIA  (Continued) 490-502 

Treatment — Dry  Middle-Ear  Catarrh. 

CHAPTER  XLI 

CHRONIC  NON-SUPPURATIVE  OTITIS  MEDIA  (Continued). 503-516 

Treatment  by  Surgical  Means — Multiple  Incisions  of  the  Drum  Mem- 
brane. 

Partial  Excision  of  the  Drum  Head — Division  of  the  Posterior  Fold. 
Tenotomy  of  the  Tensor  Tympani  Muscle. 
Otosclerosis — Symptoms,  Diagnosis,  Prognosis,  Treatment. 

CHAPTER  XLII 
DISEASES  OF  THE  PERCEPTIVE  PORTION  or  THE  HEARING  APPARATUS    517-524 

General  Consideration — Causation,  Symptoms,  Diagnosis. 
Differential  Diagnosis  between  Middle-ear  and  Labyrinthine  Diseases. 
Prognosis. 

CHAPTER  XLIII 

DISEASES  OF  THE  LABYRINTH  DUE  TO  CIRCULATORY  DISTURBANCES.  .  525-533 

Anemia  of  the  Labyrinth — Causation,  Symptoms,  Diagnosis,  Prognosis, 
Treatment. 

Hyperemia  of  the  Labyrinth — Causation,  Symptoms,  Diagnosis,  Prog- 
nosis, Treatment. 

Labyrinthine  Hemorrhage,  Meniere's  Disease — Symptoms,  Diagnosis, 
Prognosis,  Treatment. 

Embolism  or  Thrombosis — Symptoms,  Diagnosis,  Treatment. 

CHAPTER  XLIV 

INFLAMMATION  OF  THE  LABYRINTH 534-540 

Primary  Otitis  Interna. 

Secondary   Otitis   Interna   (acute) — Causation,  Symptoms,  Diagnosis, 

Prognosis,  Treatment. 
Chronic  Otitis  Interna — Causation,  Symptoms,  Diagnosis,  Prognosis, 

Treatment. 

CHAPTER  XLV 

LABYRINTHINE  SYPHILIS 541-544 

Symptoms,  Diagnosis,  Prognosis,  Treatment. 

CHAPTER  XL VI 

LABYRINTHINE  DISEASES  DEPENDENT  UPON  GENERAL  AFFECTIONS.  .  545-549 

Epidemic  Cerebrospinal  Meningitis — Symptoms,  Prognosis,  Treat- 
ment. 

Typhus  and  Typhoid  Fever — Mumps — Syphilis. 

General  Diseases,  which  Secondarily  Affect  the  Labyrinth  through 
First  Establishing  a  Suppurative  Otitis  Media. 


1 6  CONTENTS 

CHAPTER  XLVII 

PAGES 

LABYRINTH  SUPPURATION  WITH  CARIES  AND  NECROSIS  OF  THE 

PETROUS  PORTION  OF  THE  TEMPORAL  BONE 55°~553 

Symptoms,  Diagnosis,  Prognosis,  Treatment. 

CHAPTER  XLVIII 
DEAF-MUTISM 554~559 

Definition,  Pathology,  Causation,  Diagnosis,  Prognosis,  Treatment. 


INDEX 561 


Fir.,   i.-  DIAC.RAM  TO  Snow  RKI.ATIONS  OF  ORGAN  OF  HEARING  TO  BRAIN,  BLOOIJ-VKSSKI.S,  AND  N'KRVES. 

(Wales.) 


FIG.  i. — DIAGRAM  TO  SHOW  RELATIONS  OF  ORGAN  OF  HEARING  TO  BRAIN,  BLOOD-VESSELS,  AND  NERVES. 

(Wales.) 

i,  Cerebrum;  2,  third  ventricle;  3,  medulla  oblongata;  4,  condyle;  5,  Eustachian  tube;  6,  styloid  process; 
7,  mastoid  process;  8,  fissura  Santorini;  g,  cut  cartilage  of  auricle;  10,  superior  ligament  of  malleus;  n,  head 
of  malleus;  12,  external  ligament;  13,  body  of  incus;  14,  chorda  tympani  nerve;  15,  facial  nerve;  16,  aque- 
ductus  cochleae;  17,  saccule;  18,  drum  membrane;  19,  stapedius  nerve;  20,  stapes  in  vestibular  window;  21, 
superior  ligament  of  incus;  22,  cerebral  semicircular  canal;  23,  cerebellar  semicircular  canal;  24,  tympanomas- 
toid  semicircular  canal;  25,  ampullary  branch  of  vestibular  nerve  to  24  ampulla;  26,  utricle;  27,  ampullary 
branch  of  vestibular  nerve  to  22  ampulla;  28,  ampullary  branch  of  vestibular  nerve  to  23  ampulla;  29,  utric- 
ular  branch;  30,  saccus  endolymphaticus;  31,  vestibular  nerve;  32,  saccular  branch;  33,  auditory  nerve;  34, 
cochlear  nerve;  35,  membrane  of  cochlear  window;  36,  ductus  cochlearis;  37,  ductus  utriculosaccularis;  38, 
internal  carotid  artery;  39,  hypoglossal  nerve;  40,  glossopharyngeal  nerve;  41,  abducens  nerve;  42,  occipital 
artery;  43,  spinal  accessory  nerve;  44,  external  carotid  artery;  45,  glossopharyngeal  nerve;  46,  hypoglossal 
nerve;  47,  descending  branch  of  the  hypoglossal  nerve;  48,  common  carotid  artery;  49,  pneumogastric  nerve; 
50,  internal  jugular  vein. 


THE   PRINCIPLES  AND   PRACTICE 

OF 

OTOLOGY 


CHAPTER  I 

ANATOMY  OF  THE  TEMPORAL  BONE 

Introduction. — The  temporal  bone  is  one  of  the  most  important 
and  most  interesting  bones  in  the  human  skull.  Imbedded  within 
its  substance  are  the  endings  of  the  eighth  nerve,  which  spread  out, 
forming  the  complex  labyrinth,  the  cochlear  portion  of  this  nerve  passing 
to  the  organ  of  hearing  and  the  vestibular  portion  passing  to  the  organ 
of  equilibration.  The  temporal  bone  contains  a  portion  of  the  carotid 
artery.  Along  its  intracranial  surfaces  and  borders  courses  the  sigmoid 
portion  of  the  lateral  sinus,  ending  at  the  jugular  bulb,  which  forms  the 
jugular  fossa;  also  the  petrosal  sinuses,  and  at  its  apex  the  cavernous 
sinus.  The  Gasserian  ganglion  of  the  fifth  nerve  rests  in  a  hollow  near 
the  apex.  Descending  with  the  jugular  vein  are  the  glossopharyngeal, 
the  vagus,  and  the  spinal  accessory  nerves.  Roughly  speaking,  its 
whole  inner  surface  is  in  contact  with  the  dura,  covering  a  portion  of 
the  cerebrum  and  cerebellum,  while  its  outer  surface  is  covered  with 
muscles;  the  temporal  bone  gives  origin  to  eleven  muscles  and  insertion 
to  three  (Macalister),  according  to  Gray,  fifteen  muscles.  The  temporal 
bone  is  in  relation  to  the  capsule  of  the  jaw  and  to  the  parotid  gland. 

The  first  gill  cleft  (tubotympanal  sinus)  projects  from  the  pharynx 
and  forms  the  middle  ear;  the  middle  ear  includes  the  Eustachian  tube, 
the  tympanic  cavity,  and  the  antrum  with  its  mastoid  cells;  these  struc- 
tures, with  the  exception  of  the  fibrocartilaginous  portion  of  the  Eustach- 
ian tube,  all  lie  within  the  temporal  bone.  The  tympanic  portion  of 
the  middle  ear  contains  the  ossicles  with  their  muscles  and  ligaments, 
forming  the  accommodative  apparatus  of  the  organ  of  hearing  and 
connecting  the  internal  ear  with  the  external  ear.  The  tympanic  space 
lies  between  the  petrous  portion  and  the  squamotympanic  portion  of 
the  temporal  bone. 


l8  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

The  endings  of  the  eighth  nerve  are  incased  within  very  hard,  dense 
bone.  External  to  the  internal  ear  is  the  middle-ear  space,  which  is 
well  protected  from  injury  by  the  squamotympanic  portion  of  the 
temporal  bone  with  its  covering  of  muscles  and  fasciae.  Even  the  auricle 
acts  as  a  protective  pad.  Holding  the  lower  half  of  the  skull  before 
a  strong  light,  certain  parts  will  appear  translucent  and  other  parts 
opaque  (Fig.  2).  The  petrous  portion  of  the  temporal  bone  acts  as  a 
column  of  support.  This  denser  section  of  bone  passes  from  the  dense 
bone  around  the  foramen  magnum  to  the  plane  of  the  mastoid  process, 
and  helps  protect  the  base  of  the  brain,  with  its  vessels,  from  injury. 


FIG.  2. — SKULL  HELD  UP  BEFORE  A  STRONG  LIGHT. 

Note  the  thin  (lighter)  portions  of  the  central  portion  of  the  squamous  portion  of  the  temporal  bone,  the 
glenoid  fossa,  the  legmen  tympani,  and  the  occipital  bone  covering  the  posterior  brain  fossa  below  the  lateral 
sinus. 

From  the  fact  that  the  temporal  bone  contains  and  is  surrounded 
by  these  important  structures,  the  otologist  must  have  a  practical  know- 
ledge of  its  anatomy;  primarily  to  save  life  and  secondarily  to  preserve 
the  hearing.  To  obtain  this  practical  knowledge  it  is  well  to  own 
several  infant  and  adult  bones  for  study  and  reference.  With  a  jeweler's 
saw  make  seven  to  ten  horizontal  sections  of  an  adult  temporal  bone 
(Figs.  3  and  4) ;  then  make  vertical  sections  of  another.  The  student 
should  then  study  the  structure  of  the  different  sections,  noting  the 
relations  of  its  cavities  with  neighboring  dura,  sinus,  nerves,  or  blood- 
vessels; note  the  difference  between  cortical  bone  and  bone  in  contact 
with  the  dura;  also  note  carefully  the  great  differences  between  the  adult 
bone  and  the  infant  temporal  bone.  Under  instruction  perform  the 


ANATOMY   OF   THE   TEMPORAL    BONE  19 

different  mastoid  operations  on  wet  specimens  of  both  the  adult  and 
infant  temporal  bones.  For  anatomic  detail  the  student  is  referred 
to  the  works  of  Schwalbe  and  Siebenmann,  Zuckerkandl,  Testut, 
Sondermann,  Katz,  Preysing,  Shambaugh,  and  Korner. 

Position  of  the  Temporal  Bone  in  the  Skull. — The  temporal 
bone  occupies  the  lower  middle  third  of  the  side  of  the  skull  and  articu- 
lates with  five  cranial  bones.  The  temporal  bone  in  the  infant  consists 


FIG.  3. — HORIZONTAL  SECTIONS  THROUGH  ADULT         FIG.  4. — HORIZONTAL  SECTIONS  THROUGH  ADULT  TEM- 
TEMPORAL  BONE,  VIEWED  FROM  ABOVE.  PORAL  BONE,  VIEWED  FROM  BELOW. 

Figs.  3  and  4  are  views  of  the  same  temporal  bone. 

of  three  parts,  which  may  be  separated  several  months  after  birth. 
These  are  the  squamous,  the  tympanic,  and  the  petrous  portions.  These 
parts  are  united  by  fibrous  tissue  at  birth.  This  fibrous  tissue  ossifies 
toward  the  end  of  the  first  year  of  life,  sometimes  later.  The  squamous 
and  tympanic  portions  are  produced  from  fibrocartilage,  the  petrous 
and  styloid  portions  from  cartilage.  The  temporal  bone  is  weakened 
by  the  middle-ear  cavities,  the  carotid  canal,  and  by  the  external  and 


2O 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


internal  auditory  canals.  Fractures  of  the  skull  are  apt  to  follow  these 
natural  passages,  transversely  through  the  external  and  internal  auditory 
meati,  or  longitudinally  through  the  middle  ear,  depending  on  the  direc- 
tion of  the  blow,  whether  on  the  side  or  the  back  of  the  head.1 


I  Vertical 


Zygoma 


Over  tympanomastoid 
duct 


1,'ocending  portion 


Notch  of  Kivinus 
FIG.  5. — EXTERNAL  SURFACE  OF  THE  LEFT  SQUAMOUS  BONE  OF  INFANT. 

The  Squamous  Portion  of  the  Temporal  Bone. — The  squamous 
portion  forms  a  part  of  the  cranial  box  and  articulates  with  the  parietal, 
a  small  portion  of  the  frontal,  and  the  great  wing  of  the  sphenoid  bone. 
Anteriorly  its  zygomatic  process  articulates  with  the  malar  bone.  The 


ertical  portion 


Line  of  squamopetrosal 
fissure 


Zygoma 


Outer  wall  of  tympano- 

mastoid  duct 


Descending  process 


.    - 
Fi<;.  6. — INNKK  \  n  u   OK  THE  LEFT  SQUAMCH  s  BONK.  OF  INFANT. 

squamous  portion  is  like  an  inverted  letter  T  on  coronal  section,  the 
elliptic  part  forming  the  stem.  The  elliptic,  or  vertical  portion  (Figs.  5 
and  6) ,  is  thinner  in  its  central  portion  than  toward  the  periphery.  Its 

1  Read  Dr.  A.  Passow's  book  on  "Die  Verletzungen  der  Gehororganes." 


ANATOMY  OF  THE  TEMPORAL  BONE  21 

outer  surface  is  greater  than  the  inner  surface,  since  its  inner  surface  is 
beveled  and  overlaps  the  parietal  bone.  The  inner  surface  forms  a  part  of 
the  outer  boundary  of  the  middle  cranial  fossa.  The  middle  meningeal 
artery  deeply  grooves  this  inner  surface.  The  basal  horizontal  part  of 
the  squamous  bone  is  broader  anteriorly  and  vanishes  to  the  thin  vertical 
portion  posteriorly,  like  a  wedge  (Fig.  7).  Its  inner  horizontal  basal 
portion  extends  inwardly  to  join  the  external  or  tegmental  border  of  the 
petrous  bone  and  thus  forms  the  squamopetrosal  fissure.  This  fissure 
is  important  at  birth,  since  it  contains  the  squamopetrous  sinus,  which 
rarely  persists;  here,  too,  the  dura  with  blood-vessels  dips  into  the 
fissure  and  communicates  with  the  mucous  membrane  of  the  middle 
ear.  The  inner  horizontal  portion  of  the  squamous  bone  helps  in  the 
formation  of  the  outer  part  of  the  tegmen  over  the  middle  ear.  Beneath 
the  anterior  part  of  the  horizontal  portion  or  base  of  the  inverted  T 
is  the  glenoid  fossa  for  the  condyle  of  the  lower  jaw.  The  bone  in  the 
depth  of  this  fossa  is  often  as  thin  as  paper.  Posterior  to  the  glenoid 

Tip  of  descending  portion  of  squama         Notch  of  Rivinus         Clenoid  fossa 
\  \  / 

K^2i^^' 

—  Zygoma 


FIG.  7. — LEFT  SQUAMOUS  PORTION  or  TEMPORAL  BONE  OF  INFANT,  VIEWED  FROM  BELOW. 

fossa  is  the  posterior  articular  tubercle.  This  tubercle  varies  greatly 
in  its  development.  Sometimes  it  is  so  strongly  developed  that  it  forms 
a  barrier  against  which  the  jaw  would  fracture;  again  it  is  so  weakly 
developed  that  a  blow  on  the  jaw  would  fracture  the  skull.1 

Posterior  to  the  glenoid  fossa  is  that  part  of  the  squamous  bone  which 
forms  the  roof  of  the  external  auditory  meatus.  The  distance  between  the 
inner  horizontal  plate  and  the  roof  of  the  external  auditory  meatus  varies 
from  2  to  14  mm.  (see  Fig.  263).  When  the  lamellae  are  close  together 
the  brain  lies  close  to  the  roof  of  the  external  auditory  meatus,  whereas 
when  pneumatic  cells  develop  between  the  lamellae  the  thickness  may 
reach  14  mm.  The  higher  the  attic  of  the  tympanic  cavity  the  thicker 
the  bone  between  the  brain  and  the  roof  of  the  external  auditory  meatus. 
Posterior  to  the  meatal  portion  is  the  descending  plate  of  the  squamous 
bone,  which  in  the  infant  forms  the  lid,  covering  the  external  wall  of 
the  antrum  (tympanomastoid  duct).2  As  the  pneumatic  cells  which  lie 

"Die  Verletzungen  der  Gehororganes,"  von  Dr.  A.  Passow,  S.  36. 
2  In  this  bock  mastoid  antrum,  antrum,  and  tympanomastoid  duct  are  synonymous. 


22 


THE    PRINCIPLES    AND   PRACTICE   OF   OTOLOGY 


on  the  inner  surface  of  the  descending  plate  develop  along  with  the 
development  of  the  bony  external  auditory  meatus,  the  antrum  lies 
deeper  from  the  cortex,  so  that  in  the  adult  the  antrum  lies  from  15  to 
30  mm.  from  the  cortical  surface  instead  of  i  or  2  mm.,  as  in  the  infant 
at  birth.  The  posterior  part  of  the  outer  horizontal  portion  of  the 
squamous  bone  begins  at  the  posterior  part  of  the  vertical  portion  of  the 
squamous  bone  near  the  angle  of  the  incisura  parietalis,  and  widens  as  it 
extends  anteriorly  over  the  external  auditory  meatus,  forming  the  linea 
temporalis  or  supramastoid  crest  (Fig.  8).  This  crest  broadens  ante- 


Linect  temporalis 

Mastoid  fossa 
(Bezold) 

Supra- 
meatal 
spine 

Squamo- 
mastoid 
suture 


Tympanic  plate 


Mastoid  process 


Styloid  process 


FIG.  8. — LEFT  ADULT  TEMPORAL  BONE,  TO  SHOW  LANDMARKS. 

riorly  into  a  process  called  the  zygoma.  Beneath  the  linea  temporalis 
at  the  upper  posterior  part  of  the  external  auditory  meatus  is  the  spine 
of  the  suprameatus  or  spine  of  Henle.  This  spine  is  often  wanting. 
The  mastoid  fossa  is  triangular  in  shape,  about  the  size  of  the  ball  of 
the  thumb.  The  mastoid  fossa  is  bounded  above  by  the  linea  temporalis, 
anteriorly  by  the  posterior  upper  wall  of  the  meatus,  and  posteriorly, 
in  the  infant,  by  the  squamomastoid  fissure.  This  fissure  closes  in  the 
adult,  as  a  rule,  but  is  present  in  37  per  cent,  of  adult  temporal  bones, 
according  to  Sato.  The  linea  temporalis  usually  lies  somewhat  deeper 
than  the  floor  of  the  middle  fossa.  A  hole  drilled  from  the  center  of 


ANATOMY  OF  THE  TEMPORAL  BONE 


the  mastoid  fossa  parallel  to  the  upper  posterior  wall  of  the  external 
auditory  canal  is  the  most  direct  route  to  the  mastoid  antrum  (tympano- 
mastoid  duct).  A  line  drawn  from  the  incisura  parietalis  to  the  tip  of 

Squama 


Zygoma 


Tympanic  plate     ~ 


Anterior   limb  of 
tympanic  bone 


Linea  temporalis 


Squamomastoid  suture 
Notch  of  Rivinus 


FIG.  9.  —  SQUAMOTYMPANIC  PORTION  OF  LEFT  TEMPORAL  BONE  or  INFANT,  EXTERNAL  VIEW. 

the  mastoid  is  called  Macewen's  line,  and  in  the  adult  it  passes  through 
the  anterior  border,  the  middle,  or  the  posterior  border  of  the  sigmoid 
sinus.  This  line  in  the  infant  is  far  anterior  to  the  sigmoid  sinus. 


Squamopetrosal  fissure  \ 


Outer  wall  of  tympano- 
mastoid  duct 


External  wall  of  attic 


Posterior  tymprnic 
tubercle 


Vertical  portion  of 
squama 


-    Zygoma 


I  Posterior  tympanic 
spine  (Henle) 

-  Sulcus  malleolaris 


Tympanic  sulcus 


Anterior  tympanic  spine 


FIG.  10. — INNER  VIEW  OF  SQUAMOTYMPANIC  PORTION  OF  LEFT  TEMPORAL  BONE  OF  INFANT. 

The  Tympanic  Bone  (Fig.  9). — The  tympanic  portion  of  the  tem- 
poral bone  in  the  infant  is  shaped  like  a  ring  open  above  and  anteriorly. 
The  inner  part  of  the  ring,  or  annulus  tympanicus,  is  grooved  and 


24  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

called  the  tympanic  sulcus,  which  gives  attachment  to  the  drum  mem- 
brane (Figs.  10  and  u).  Anteriorly  it  is  separated  from  the  squamous 
bone  by  the  Glaserian  fissure.  Posteriorly  it  is  separated  from  the 
mastoid  portion  of  the  petrous  bone  by  the  tympanomastoid  fissure. 
The  styloid  process  is  directed  downward  and  forward  from  the  most 
prominent  part  of  the  vaginal  process  of  the  tympanic  bone  (see  Fig. 
8).  In  operating  upon  the  bulb  the  styloid  process  is  an  important 
landmark.  Immediately  internal  to  the  styloid  process  is  the  jugular 
bulb. 

Portion  of  tegmen  tympani          Tympanic  bone 

\ 


—    -Glenoid  fossa 


^-Zygoma 

I 
FIG.  u. — LEFT  SQUAMOTYMPANIC  PORTION  OF  TEMPORAL  BONE  OF  INFANT,  VIEWED  FROM  BELOW. 

The  Petrous  Bone. — The  petrous  portion  is  the  most  important 
part  of  the  temporal  bone.  It  is  an  irregular  four-sided  pyramid  with 
its  oblique  base  projecting  backward,  so  that  it  is  much  larger  than  the 
base  of  a  quadrilateral  pyramid.  The  base  forms  a  small  portion  of  the 
external  surface  of  the  skull  and  is  called  the  mastoid  region  (see  Fig.  8). 
The  projecting  intracranial  part  of  the  base  is  grooved  by  the  sigmoid 
sinus.  The  groove  is  generally  deeper  and  wider  on  the  right  side  of 
the  skull  than  on  the  left.  At  birth  there  is  no  mastoid  process,  nothing 
but  a  small  tubercle  (Fig.  12),  which  slowly  develops  until  about  the 
third  year  it  assumes  the  adult  type.  The  apex  of  the  quadrilateral 
pyramid  is  directed  forward  and  inward  to  the  anterior  lacerated  fora- 
men. The  pyramid  has  an  upper,  a  lower,  an  inner,  and  an  outer 
border.  Two  of  its  surfaces  are  intracranial  and  two  are  extracranial. 
The  intracranial  surfaces  face  upward,  the  extracranial  surfaces  face 
downward.  The  intracranial  surfaces  are  called  the  anterior  upper 
or  cerebral  surface,  and  the  posterior  upper  or  cerebellar  surface. 
The  extracranial  surfaces  are  called  the  anterior  lower  or  tympanic 
surface,  and  the  posterior  lower  or  jugular  surface.  The  base  or  mas- 
toid region  is  five  sided  in  shape  and  projects  beyond  the  base  of  the 
pyramid,  forming  an  intracranial  surface.  The  base  is  rough  externally. 
It  is  bounded  above  by  the  parietomastoid  suture;  anteriorly  by  the 
squamomastoid  suture  and  tympanomastoid  fissure;  a  lower  border  to 
which  the  digastric  muscle  is  attached  and  a  posterior  border  bounded 


ANATOMY  OF  THE  TEMPORAL  BONE  25 

by  the  occipitomastoid  suture.  The  mastoid  process  varies  greatly 
in  size  and  shape.  Its  tip  is  usually  directed  forward  and  downward. 
Into  its  outer  rough  surface  the  sternocleidomastoid,  the  splenius  capitis, 
and  the  trachelomastoid  muscles  are  attached.  Internal  to  the  mastoid 
tip  is  the  digastric  fossa,  to  which  the  digastric  muscle  is  attached; 
behind  this  is  a  ridge  which  is  sometimes  so  greatly  developed  that  it 
resembles  a  second  mastoid  tip.  Internal  to  this  ridge  is  the  groove 
for  the  occipital  artery.  The  stylomastoid  foramen  lies  at  the  anterior 
end  of  the  digastric  groove  behind  the  styloid  process.  Near  the 
occipitomastoid  suture,  and  sometimes  within  it,  are  from  one  to 
five  holes — as  a  rule  only  one  or  two — called  the  mastoid  foramina. 


Squamo- 
mastoid 
fissure 


;   Mastoid 
tubercle 

Stylo- 
mastoid 
foramen 


FIG.  12. — LEFT  TEMPORAL  BONE  OF  INFANT. 

That  part  of  the  base  which  is  intracranial  is  concave  and  forms  the 
anterolateral  portion  of  the  posterior  fossa. 

Mastoid  Process. — The  mastoid  process  makes  up  the  base  of  the 
petrous  portion  and  forms  the  posterior  and  the  lower  part,  while  the 
squamous  portion  forms  the  anterior  and  upper  part  (Fig.  13).  The 
anterior  border  is  thick  and  rounded  and  generally  vertical.  The  infant 
at  birth  has  no  mastoid  process.  At  the  age  of  three  years  the  mastoid 
process  assumes  the  adult  type  and  continues  to  grow  till  it  attains  the 
full  development  of  the  adult  mastoid  (see  Fig.  36).  Above  and  anterior 
to  the  squamomastoid  suture  in  the  infant  at  birth  is  the  cavity  of  the 
antrum  (tympanomastoid  duct  of  Sondermann) ,  and  this  is  the  important 
landmark  in  opening  the  infant  antrum.  Posterior  and  below  this 


26 


Ilii:     I'KINCIIM.KS    AMI    PKACTICI.    OK    OTOLOGY 


suture  is  the  cartilaginous  bone  of  the  petrous  bone  containing  the 
semicircular  canals.  Below  and  apparently  about  the  middle  of  the 
posterior  arm  of  the  tympanic  ring  appears  the  exit  of  the  facial  nerve 
(see  Fig.  12).  In  the  adult  the  squamomastoid  suture  loses  its  surgical 
importance,  and  in  those  cases  where  it  persists-  extends  from  the  parietal 
notch  obliquely  across  the  mastoid  in  the  direction  of  the  tip.  By  the 
development  of  the  mastoid  cells  from  the  floor  of  the  antrum  (petrous 
portion)  and  the  development  of  the  cells  forming  the  external  cover 
of  the  antrum  (squamous  portion)  this  suture  moves  downward  and 


Carotid  canal  - 


Zygoma 


Glaserian  fissure 
Tympanic  plate 


External  auditory  canal 

Mastoid  process 
Squamomastoid  suture 


Styloid  process 


FIG.  13. — ANTERIOR  VIEW  OF  LEFT  ADULT  TEMPORAL  BONE. 

backward.     The  periosteum  is  often  closely  adherent   and  dips  into 
this  suture. 

The  mastoid  cells  may  be  pneumatic  (36.8  per  cent.),  diploetic 
(20  per  cent.),  or  a  combination  of  pneumatic  and  diploetic  (43  per  cent.). 
By  pathologic  changes  the  bone  may  become  compact  and  hard  like 
ivory.  The  size  of  the  adult  mastoid  process  is  variable,  depending 
on  the  size  and  the  position  of  the  sigmoid  sinus  in  its  relation  to  the 
external  auditory  canal  (see  Fig.  18).  The  depth  is  also  variable.  The 
depth  of  the  antrum  varies  from  2  to  30  mm.  from  the  mastoid  fossa. 
To  find  the  antrum,  enter  the  mastoid  fossa  below  the  linea  temporalis 


ANATOMY  OF  THE  TEMPORAL  BONE 


27 


and  chisel  in  a  direction  parallel  to  the  upper  posterior  wall  of  the 
external  auditory  canal.  Operate  in  every  case  as  if  the  most  dangerous 
condition  existed;  that  is,  as  if  the  sinus  came  close  to  the  external 
auditory  canal.  The  cortex  of  the  mastoid  may  be  thin  as  paper  or 
it  may  be  very  thick  and  hard  (6  mm.). 

PNEUMATIC  CELLS  IN  THE  TEMPORAL  BONE  OF  THE  INFANT 
In  the  infant  the  cellular  construction  is  not  so  extensively  developed 
as  in  the  adult.     The  bony  cells  extend  from  the  floor  of  the  tympanic 


Zygomatic  cells  Tympanomastoid  sinus  (mastoid  antrum) 


Annulus  tympanicus   I 


Squamomastoid  fissure 

Tympanomastoid  semicircular  canal 
•  Canals  often  opened  in  attempted 
/    mastoid  operation  on  infants 
Cerebellar  semicircular  canal 


eventh  and  eighth  nerves 


Carotid  artery  Cochlea 


FIG.  14.  —  -VIEW  OF  TYMPANIC  OR  ANTERIOR  INFERIOR  SURFACE  OF  INFANT  LEFT  TEMPORAL  BONF.  FROM  A 
CORROSION.    (Prepared  by  Wales.) 

cavity  along  the  tegmen,  around  the  Eustachian  tube,  and  around  the 
antrum  (tympanomastoid  duct).     This  development  is  well  shown  in 


Cerebral  semicircular  canal  Cerebellar  semicircular  canal 

\ 


Internal    auditory    meatus 
(seventh  and  eighth  nerves) 


\  Represents  fossa 
i     subarcuata 


—  Tympanomastoid  semi- 
circular canal 


^Facial  nerve 
Jci:      ^ 

Superficial  petrosal  nerves 

FIG.  15. — VIEW  OF  CEREBRAL  OR  ANTERIOR  SUPERIOR  SURFACE  OF  INFANT  LEFT  TEMPORAL  BONE  FROM  A 
CORROSION.    (Prepared  by  Wales.) 

corrosions  of  the  infant  temporal  bone  (Figs.  14  to  17).     In  the  adult 
the  growth  of  pneumatic  cells  invades  the  whole  substance  of  the  tern- 


28 


THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

Ccrclx'llar  semicircular  canal 


Section  of  seventh  and  eighth  nerves 


Cochle 


Tympanomastoid  semicircular  canal 


B  Represents  fossa  suharcuata 
—  - —  Cerebral  semicircular  cana  1 


Vestibule 


Facial  nerve 

FIG.  16.  —  VIEW  OF  CEREBELLAR  OR  POSTERIOR  SUPERIOR  SURFACE  OF  INFANT  LEFT  TEMPORAL  BONE  FROM 
A  CORROSION.    (Prepared  by  Wales.) 

Annulus  tympankus 


Cerebellar  semicircular 

canal 


Cochlea  — 
Carotid  artery  — 


Tympanomastoid  semi- 
circular canal 

Internal  auditory  meatus 
representing  seventh 
and  eighth  nerves. 


FIG.  17. — VIEW  OF  JUGULAR  OR  POSTERIOR  INFERIOR  SURFACE  OF  INFANT  LEFT  TEMPORAL  BONE  FROM  A 
CORROSION.    (Prepared  by  Wales.) 

External  auditory  canal 
Zygomatic  cells  Tympanomastoid  duct  (mastoid  antrimi) 

/ ' ,  :        Sigmoid  sinus 


Tubercle  of  zygoma        Styloid  process 
FIG.  18. — SKULL  SHOWING  GREAT  DEVELOPMENT  OF  ZYGOMATIC  CELLS.     (Wales.) 


ANATOMY  OF  THE  TEMPORAL  BONE 


29 


poral  bone  except  over  the  cerebral  and  tympanomastoid  semicircular 
canals,  the  promontory,  and  around  the  internal  and  external  auditory 
meatus.  The  mastoid  cells  vary  in  size  in  the  adult.  A  large  cell  at 
the  mastoid  tip  is  common.  The  cells  sometimes  invade  the  zygoma 
and  the  squamous  part  of  the  temporal  bone  (Fig.  18).  The  cells 
may  also  extend  around  the  Eustachian  tube  and  the  carotid  canal. 
Another  group  of  cells  extends  between  the  sigmoid  sinus  and  the  facial 
canal  to  the  bulb  of  the  jugular;  the  cells  extend  backward  toward  the 
occiput;  they  often  extend  downward  to  join  the  cells  of  the  occipital 
bone  and  communicate  with  the  sphenoid  sinus  and  nasopharynx. 
These  cells  are  lined  by  mucous  membrane,  which  in  turn  may  divide 
the  bony  mastoid  cells. 

THE  PETROUS  BONE 

The  cerebral,  or  superior  anterior  surface  of  the  petrous  bone,  forms 
the  posterior  part  of  the  floor  of  the  middle  fossa  (Fig.  19).  Near  its 
apex  is  the  hollow  for  the  Gasserian  ganglion  of  the  fifth  nerve.  The 


Gasserian  fossa 


Cerebral  semicircular  canal 


Tegmen  tympani 


Superior  petrosal  sinus 


Zygoma  Tegmen  over  tympanomastoid  duct 

FIG.  19. — THE  SUPERIOR  ANTERIOR  OR  CEREBRAL  SURFACE  OF  THE  ADULT  PE 


ITROUS  BONE. 


greater  superficial  petrosal  nerve  passes  forward  from  the  hiatus  Fallopii 
in  a  small  groove  to  the  anterior  lacerated  foramen  (Fig.  20) ;  a  smaller 
hole,  external  to  the  hiatus  Fallopii,  gives  exit  to  the  lesser  petrosal  nerve, 
a  continuation  of  the  tympanic  nerve.  This  nerve  runs  parallel  to  the 
great  superficial  petrosal  nerve.  The  eminentia  arcuata  is  the  outcrop- 
ping of  the  superior  cerebral  semicircular  canal.  External  to  this 
eminence  is  the  tegmen  tympani  and  antri.  This  part  of  the  cerebral 
surface  may  be  thin  as  paper  or  may  be  entirely  lacking  in  parts  (dehis- 


THE   PRINCIPLES   AND    PRACTICE    OF   OTOLOGY 


cences).     These  dehiscences  are  filled  in  with  fibrous  tissue  and  hence 
may  become  pus  channels  connecting  the  cerebral  fossa  with  the  middle 


Cerebral  semicircular  canal 

' 


Fossa  subarcuata  • 


Spurious  opening  of 

facial  canal 


FIG.  20. — SUPERIOR  ANTERIOR  OF  CEREBRAL  SURFACE  OF  LEFT  PETROUS  PORTION  OF  INFANT  TEMPORAL 

BONE. 

ear.  External  to  the  tegmen  is  the  petrosquamous  suture.  In  the 
infant  the  suture  is  like  a  fissure,  filled  in  with  fibrous  tissue  and  pierced 
by  blood-vessels. 


Cerebral  semicircular 
canal 


Aqueductus 
vestibuli 


Aqueductus 
cochleae 


Styloicl  process. 


FIG.  21. — INNER  ASPECT  OF  LEFT  ADULT  TEMPORAL  BONE. 
Showing  landmarks  of  the  posterior  superior  or  cerebellar  surface  of  petrous  portion  of  temporal  bone. 

The  Cerebellar  Surface  of  the  Petrous  Bone. — The  cerebellar,  or 
posterior  superior  surface,  is  in  relation  to  the  cerebellum  and  forms  the 


ANATOMY  OF  THE  TEMPORAL  BONE  3! 

anterolateral  wall  of  the  cerebellar  fossa  (Fig.  21).  Nearer  the  superior 
border  than  the  inferior  border  and  about  midway  between  the  apex 
and  the  anterior  border  of  the  sigmoid  sulcus  is  the  internal  auditory 
meatus,  which  is  surrounded  by  dense  bone.  Its  axis  is  nearly  in  a  line 
with  that  of  the  external  auditory  meatus.  In  the  depth  of  the  internal 
auditory  meatus  there  is  a  transverse  ridge,  called  crista  transversa,  divid- 
ing the  fundus  into  an  upper  and  lower  half  (Fig.  22).  In  the  anterior 
upper  half  there  is  a  foramen  for  the  passage  of  the  facial  nerve;  pos- 
terior to  this  is  the  area  vestibularis  superior,  with  several  fine  openings 
in  which  the  upper-end  branches  of  the  vestibular  nerve  are  conducted 
to  the  macula  cribrosa  superior  of  the  vestibule.  The  lower  half  con- 
tains a  grooved  area  called  the  area  cochleae,  which  contains  a  broad 
spiral  groove  with  numerous  openings  for  the  branches  of  the  cochlearis 
nerve,  called  the  tractus  spiralis  foraminosus.  In  the  posterior  part  of 


Cerebral  semicircular  canal 

Inferior  petrosal  sulcus     ' 

fKT   £^lr^      S  ~   Fossa  subarcuata 

Apex    — 
FIG.  22. — SUPERIOR  POSTERIOR  OR  CEREBELLAR  SURFACE  OF  LEFT  PETROUS  BONE  OF  INFANT. 

the  lower  half,  near  the  crista  transversa,  is  a  field  with  small  openings, 
called  the  area  vestibularis  inferior,  containing  fine  openings  of  canals 
which  carry  bundles  of  the  vestibular  nerve  to  the  macula  cribrosa  media 
of  the  vestibule.  Somewhat  medially  and  posterior  from  this  area  is 
a  single  large  hole,  called  the  foramen  singulare,  which  conducts  the 
nerve  ampullaris  posterior  to  the  macula  cribrosa  inferior. 

The  Facial  or  Fallopian  Canal. — The  facial  canal  begins  at  the 
internal  auditory  canal  and  ends  at  the  stylomastoid  foramen  and  has 
an  opening  on  the  cerebral  surface  of  the  petrous  bone  called  the  spurious 
opening  (Fig.  23).  Since  the  facial  canal  is  not  straight  between  the  en- 
trance and  exit,  but  forms  two  knee-like  bends,  it  may  be  divided  into 
three  parts  (see  Fig.  i).  The  first  and  shortest  section  begins  at  the 
upper  anterior  part  of  the  fundus  of  the  internal  auditory  canal  and 
passes  laterally  to  the  spurious  opening;  here  the  canal  bends  posteriorly 
the  inner  wall  of  the  tympanic  cavity  and  passes  above  the  vestibular 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


window  (at  this  point  a  dehiscence  is  common)  till  it  reaches  the  emi- 
nentia  pyramidalis  posteriorly;  above  the  canal  lies  the  prominence  of  the 
tympanomastoid  lateral  semicircular  canal.  The  length  of  the  middle 


Suit  us  tympanicus 

Floor  of  hypotym- 
panum 

Facial  nerve 


Mastoid  vein       Mustoid  vein     Floor  of  tympanomastoid  duct 

~"  (mastoid  antrum) 


Sigmoid  sinus 

)  Crus  of  cerebral 

I  semii  ircular  canal 

Vestibule 
Eighth  nerve 
Seventh  nerve 


Geniculate  ganglion 

Great  superficial 
petrosal  nerve 

Eustachian  tube 
Carotid  artery 


Jugular  bulb 

FIG.  23. — TRANSVERSE  SECTION  THROUGH  RIGHT  TEMPORAL  BONE,  FROM  ABOVE. 
Berlin  Anatomical  Institute.     (Wales.) 

section  of  the  canal  is  about  6  mm.     The  canal  has  a  medial  portion  in 
relation  to  the  labyrinth  wall  and  a  lateral  wall  which  projects  into  the 


Handle  of  malleus 
Chorda  tympani  nerve  \ 


Osseous  Eustachian  tube 


—   Pneumatic  mastoid  cells 


Large  tip  cell 


FIG.  24.  —  RIGHT  TEMPORAL  BONE. 
Vertical  section  through  middle  ear,  viewed  from  within. 

tympanic  cavity  and  is  often  so  thin  that  the  nerve  shines  through  it. 
This  wall  is  penetrated  by  a  hole  through  which  the  stapedial  artery, 
a  branch  of  the  stylomastoid  artery,  passes,  and  is  important  on  account 


ANATOMY  OF  THE  TEMPORAL  BONE 


33 


of  disease  processes  of  the  middle  ear  making  their  way  to  the  facial 
canal.  The  third  and  last  section  lies  between  the  eminentia  pyramid- 
alis  and  the  stylomastoid  foramen  (Fig.  24).  Above  the  stylomastoid 
foramen  the  canal  for  the  chorda  tympani  nerve  is  given  off,  which  ends 
at  an  opening  on  the  posterior  wall  of  the  tympanic  cavity  behind  the 
sulcus  of  the  membrana  tympani. 

The  size  of  the  spurious  opening  varies  greatly;  sometimes  it  is  so 
wide  that  on  detaching  the  dura  mater  the  geniculate  ganglion  is  visible, 
while  in  other  cases  it  is  so  small  that  it  is  hard  to  find. 


Lateral  sulcus 


Mastoid  foramen 


Superior  petrosal  sulcus 

Internal  auditory  meatus 


Aqueduct  of  vestibule 


Aqueduct  of  cochlea 


Tip  of  mastoid  process 

Styloid  process  . 

FIG.  25. — ADULT  LEFT  TEMPORAL  BONE,  VIEWED  FROM  BEHIND. 

Below  the  internal  auditory  meatus  is  the  three-sided  aqueductus 
cochleae  (Fig.  25).  The  cerebellar  surface  is  shorter  than  the  other 
two  sides  and  so  presents  a  sulcus.  The  depth  of  the  aqueductus 
cochleae  is  seen  best  from  the  jugular  surface  of  the  petrous  bone.  The 
aqueductus  cochleae  is  about  10  mm.  long  and  begins  at  the  floor  of  the 
scala  tympani  in  the  neighborhood  of  the  cochleae  window.  From  the 
jugular  surface  of  the  petrous  bone  the  aqueductus  cochleae  looks  like 
a  bayonet  or  specula.  This  canal  forms  a  communication  between  the 
perilymphatic  fluid  of  the  internal  ear  and  the  arachnoid  space  of  the 
posterior  brain  fossa.  The  vena  aqueductus  cochleae  is  relatively  of 


34 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


large  size  and  runs  in  a  canal  of  its  own,  the  canalis  accessorius  aqueduc- 
tus  cochleae,  and  takes  the  venous  blood  from  all  the  cochleae  canals, 
as  well  as  part  of  the  vestibule,  and  empties  into  the  bulb  of  the  jugular 


vein. 


1.  Eyeball. 

2.  Ophthalmic  vein. 

3.  Sinus  of  the  lesser  wing  of  the 

sphenoid. 

4.  Cavernous  sinus. 

5.  Circular  sinus  of  Ridley. 

6.  Superior  petrosal  sinus. 
-.  Inferior  petrosal  sinus. 

8.  Occipital  sinus. 

9.  Internal  auditory  vein. 

10.  Bulb  of  the  jugular  vein. 

11.  Vein  of  the  aqueduct  of  the  cochlea 

12.  Descending  portion  of  the  trans- 

verse sinus. 

13.  Horizontal  portion  of  the  trans- 

verse sinus. 


14.  Vein  of  the  aqueduct  of  the 

vestibule. 

15.  Emissary  of  Santorini  (pos- 

terior condyloid  foramen). 

16.  Vertebral  plexus. 

17.  Mastoid  vein. 

18.  Occipital  vein. 

19.  External  jugular  vein. 

20.  Common  or  internal  jugular 

vein. 

21.  Subclavian  vein. 

22.  Innominate  vein. 

23.  Superior  caya. 

24.  Right  ventricle. 

25.  Foramen   magnum   (occipi- 

tale). 


FIG.  26. — DIAGRAM   OF  THE  VENOUS  SYSTEM  THAT  CARRIES  OFF   THE  BLOOD   FROM  THE  INTERIOR  or 

THE  CRANIUM. 
Base  of  the  skull,  viewed  from  above  and  behind.     (Briihl  and  Politzer.) 

Between  the  internal  auditory  meatus  and  the  cerebral  surface  along 
the  superior  border  of  the  petrous  bone  runs  the  superior  petrosal 
sinus,  from  the  sigmoid  sinus  to  the  cavernous  sinus.  Below  this  sinus 
and  behind  the  internal  auditory  meatus  is  the  fossa  subarcuatus,  very 


ANATOMY  OF  THE  TEMPORAL  BONE  35 

large  in  the  infant,  tunneling  under  the  cerebral  semicircular  canals 
(see  Fig.  22).  In  the  adult  bone  the  fossa  subarcuatus  is  often  wanting, 
often  marked  by  a  small  foramen.  Behind  and  below  the  fossa  sub- 
arcuatus is  the  slit-like  opening  of  the  aqueductus  vestibuli,  covered  by  a 
thin  plate  of  bone.  The  aqueductus  vestibuli  begins  with  two  thin  forked 
tubes,  one  leading  from  the  utricle  and  the  other  from  the  saccule. 
These  tubes  join  and  form  a  common  tube  which  is  5  to  6  mm.  long, 
ending  at  the  hiatus  aqueductus  vestibuli,  where  it  spreads  out  toward 
the  sigmoid  sinus  into  a  blind  sac  about  15  mm.  long  in  the  dura  mater, 
called  the  saccus  endolymphaticus  (see  Fig.  i).  The  base  of  the  cere- 
bellar  surface  ends  at  the  anterior  border  of  the  sigmoid  sinus;  its 
borders  are  nearly  surrounded  by  venous  sinuses  (Fig.  26). 

The  Jugular  Surface  or  Inferior  Posterior  Surface. — This  sur- 
face is  the  most  irregular  of  the  surfaces  of  the  petrous  bone  (Fig.  27). 


Foramen  for  auricular  nerve 

\      Aqueductus 
Jugular  fossa       \      cochlea      _^EStt^F       /  Carotid  canal 

\\ 


Stylomastoid  foramen 


M;istoid 
process  i  \  v 

Styloid  process        Fissure  of     Glenoid  fossa  Zygoma 

Glaser 

FIG.  27. — ADULT  LEFT  TEMPORAL  BONE,  VIEWED  FROM  BELOW. 

The  apex  is  rough  and  covered  by  the  cartilage  of  the  occipitopetrosal 
synchondrosis.  About  midway  between  the  apex  and  the  base  is  the  oval 
opening  of  the  carotid  canal.  The  carotid  canal  ascends  along  the  an- 
terior wall  of  the  tympanic  cavity  to  the  bony  wall  of  the  Eustachian  tube 
and  then  bends  in  a  horizontal  direction,  ending  at  the  apex  of  the  petrous 
bone.  The  lateral  and  upper  walls  are  formed  by  a  thin  plate  which  is 
often  defective;  frequently  in  detaching  the  dura  from  the  middle  fossa  a 
long  strip  of  the  horizontal  portion  of  the  carotid  canal  is  exposed.  The 
medial  wall  of  the  perpendicular  ascending  portion  of  the  canal  forms 
the  anterior  wall  of  the  tympanic  cavity.  This  wall  is  thin  and  perforated 


36  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

by  small  holes  which  carry  vessels  and  nerves.  This  wall  is  sometimes 
wanting.  If  the  defect  is  great  the  internal  carotid  artery  may  project 
into  the  tympanic  cavity.  The  horizontal  part  of  this  canal  is  in  relation 
to  the  cochleae  and  is  tangent  to  the  first  turn  of  the  cochlea.  Between 
the  internal  carotid  artery  and  its  canal  there  is  a  network  of  veins. 
External  to  the  carotid  opening  is  the  vaginal  process  of  the  tympanic 
plate.  Just  behind  the  opening  is  a  sharp  ridge  called  the  carotid  ridge, 
which  separates  the  carotid  and  jugular  fossae.  The  jugular  fossa  at 
birth  scarcely  shows  any  depression  for  the  bulb  of  the  jugular  vein 
(Fig.  28).  The  size  and  extent  of  this  fossa,  as  well  as  the  thickness  of 
its  walls,  seems  to  depend  on  the  size  of  the  jugular.  According  to 
Zuckerkandl  the  fossa  is  larger  on  the  right  side  in  54  per  cent,  of  cases 
than  on  the  left,  and  of  equal  size  in  14  per  cent.  If  the  jugular  fossa 
is  deep  the  cellar  of  the  tympanic  cavity  is  shallow  and  the  floor  is  often 

Stylomastoid  foramen 


Annulus  tympanicus  — 

^!%^  */^ 

I    Jugular  fossa 
Carotid  canal 
Apex  — 

FIG.  28. — PETROUS  PORTION  OF  LEFT  INFANT  TEMPORAL  BONE. 
Showing  inferior  posterior  or  jugular  surface  of  petrous  bone. 

thin  as  paper.  The  jugular  bulb  may  project  into  the  tympanic  cavity 
(Fig.  29).  Dehiscences  sometimes  occur,  but  the  danger  of  cutting  the 
jugular  bulb  in  incising  the  drum  membrane  is,  according  to  C.  Grunert, 
as  dangerous  as  the  possibility  of  a  falling  star  striking  one's  head.  By 
extension  of  its  inner  half  and  by  dehiscences  the  vestibule  and  the 
internal  auditory  canal  may  be  opened,  and  the  jugular  bulb  is  then  in 
relation  to  the  structures  of  these  spaces.  If  the  fossa  jugularis  is 
shallow  the  floor  of  the  tympanic  cavity  may  be  from  5  to  6  mm.  thick. 
Most  temporal  bones  appear  translucent  on  holding  them  up  before  a 
light  (see  Fig.  2).  The  floor  of  the  tympanic  cavity  appears  light  on 
looking  through  the  external  auditory  meatus.  In  the  carotid  ridge 
is  a  minute  opening  for  the  tympanic  branch  of  the  glossopharyngeal 
nerve.  Behind  the  vaginal  process  of  the  tympanic  plate  is  the  styloid 
process,  and  behind  the  styloid  process  and  at  the  anterior  end  of  the 


ANATOMY  OF  THE  TEMPORAL  BONE 


37 


digastic  fossa  is  the  Fallopian  canal,  where  the  facial  nerve  leaves 
the  petrous  bone.  When  the  jugular  fossa  is  small  and  insignificant 
on  the  jugular  surface  of  the  petrous  bone  the  jugular  bulb  may  make 

Small  superficial  petrosal  nerve 

\      Large  superficial  petrosal  nerve 
Stapes        Facial  nerve      \      \  Carotid  artery 


Sigmoid 
portion 
of  lateral 
sinus 


Eustachian  tube 
Tympanic  branch 

of  glossopharyn- 

geal  nerve 
Bulb  of  jugular  vein 

Carotid  artery 
Occipital  condyle 


FIG.  29. — VERTICAL  SECTION  THROUGH  MIDDLE  EAR.    (Wales.) 

compensatory  room  in  the  occipital  bone,  thus  the  size  of  the  jugular 
fossa  does  not  necessarily  indicate  the  size  of  the  jugular  vein. 

The  Tympanomastoid  or  Anterior  Inferior  Surface  of  the  Petrous 
Bone  (Fig.  30). — This  wall  is  the  most  interesting  and  important  to  the 


Spurious  opening  of  facial  canal 


Cerebral  Yestibular         Tympano- 

semicircular  canal          window        mastoid  sinus 


Squamomas- 
toid  suture 


FIG.  30. — ADULT  LEFT  TEMPORAL  BONE. 
Squamous  portion  of  temporal  bone  has  been  broken  off,  leaving  petrous  and  tympanic  portions. 

otologist  because  it  is  the  operative  gateway  to  the  petrous  bone  and 
the  limiting  wall  of  mastoid  and  middle-ear  operations.  On  the  inner 
wall  of  the  antrum  or  tympanomastoid  duct  is  the  hard  white  bone  of 
the  tympanomastoid  horizontal  semicircular  canal.  This  is  an  important 


38  THE    PRINCIPLES    AND   PRACTICE    OF   OTOLOGY 

landmark  in  operations  on  the  mastoid  and  vestibule.  Beneath  the 
semicircular  canal  is  the  horizontal  portion  of  the  facial  canal,  and 
beneath  the  smooth,  thin  bony  wall  containing  the  facial  nerve  is  the 
fossa  which  contains  the  vestibular  window  in  which  the  foot-plate  of 
the  stapes  is  attached  by  fibrous  tissue,  called  the  annular  ligament. 
Immediately  below  and  slightly  posterior  is  the  tympanic  sinus.  Pro- 
jecting over  this  sinus  in  its  posterior  part  is  the  pyramid  through  which 
the  ligament  of  the  stapedius  muscle  passes  to  the  head  of  the  stapes. 
And  at  the  lowest  anterior  part  of  this  sinus  is  the  niche  leading  to  the 
cochlea  window.  The  sinus  varies  in  size  and  sometimes  undermines 
the  cerebellar  posterior  semicircular  canal  (Fig.  31). 

Anterior  to  the  fossa  is  the  promontory,  which  is  formed  by  the  first 
turn  of  the  cochlea.  On  the  promontory  are  grooves  for  the  plexus 
tympanicus.  Posterior  and  inferior  to  the  promontory  is  the  jugular 

Epitympanum  (attic)  Tympanomastoid  duct 

V  I 

\ 
\ 


Vestibular  window 


Niche  to  cochlea  window    — 


—  Line  of  squamomustoid 
fissure 


—  Tympanic  sinus 


Stylomastoid  foramen 

^^nir  j*5i  nHun>" 

Eustachian  tu!/e          ^^~^fl^ 

. 

Annulus  ty.npanLus 

FIG.  31. — LEFT  PETROUS  PORTION  OF  INFANT'TEMPORAL  BONE. 
Showing  inferior  anterior  or  tympanic  surface  of  petrous  bone. 

wall  covering  the  jugular  bulb.  The  bulb  may  mount  up  as  high  as 
the  niche  of  the  cochlea  window.  Immediately  beneath  the  promontory 
there  are  some  pneumatic  cells,  called  tympanic  cells,  and  anterior 
there  is  a  smooth  surface  leading  to  the  Eustachian  tube.  Immediately 
above  the  promontory  and  projecting  into  the  tympanic  cavity  is  the 
bony  canal  for  the  tensor  tympani  muscle.  Its  termination  immediately 
anterior  to  the  stapes  and  on  a  level  with  the  facial  canal  is  called  the 
processus  cochleariformis.  This  bony  canal  (canalis  musculotubarius) 
lies  near  the  tegmen  and  runs  along  the  roof  to  the  Eustachian  tube. 
Internal  to  the  opening  of  the  Eustachian  tube  is  a  thin  bony  wall 
covering  the  carotid  canal  (Fig.  32). 

The  Infant  Temporal  Bone. — Some  of  the  differences  between  the 
adult  bone  and  the  infant  temporal  bone  are  as  follows: 

In  the  infant  there  is  no  osseous  external  auditory  canal.     The 


ANATOMY  OF  THE  TEMPORAL  BONE 


39 


mastoid  process  does  not  exist.  It  is  indicated  by  a  small  tubercle 
without  pneumatic  cells.  The  antrum  lies  superficially.  The  fissures 
petrososquamosa  and  squamosomastoidea  are  present.  The  internal 
auditory  canal  is  wide  and  shallow  and  the  landmarks  at  the  fundus 
of  the  canal  are  easily  discerned.  The  contour  of  the  cerebral  and 
cerebellar  semicircular  canals  are  more  prominent  than  in  the  adult. 
The  fossa  subarcuata  is  large.  The  fossa  jugularis  is  flat.  The  swollen 
fetal  mucous  membrane  fills  up  the  tympanic  cavity  and  is  slowly  ab- 
sorbed. This  process  of  absorption  takes  place  most  slowly  on  the 
roof  of  the  tympanic  cavity  and  in  the  mastoid  antrum.  The  Eustachian 


Roof  of  tympanomastoid  sinus  (antrum) 


Facial  nerve 

Stapedius  muscle  tendon 
Vestibule 


External  auditory 
canal 


Stenosis   of   carotid 
artery 


Tympanic  cavity  Fatty  tissue 

FIG.  32. — TRANSVERSE  SECTION  THROUGH  THE  LEFT  TEMPORAL  BONE,  FROM  BELOW. 
From  a  section  obtained  from  the  Berlin  Anatomical  Institute.     (Wales.) 

tube  is  relatively  wide  and  short  and  on  a  level  with  the  hard  palate. 
Its  upper  and  lower  walls  lie  on  each  other  in  the  median  section.  This 
narrow  cleft  is  filled  with  loosened  and  macerated  epidermis.  The 
drum  membrane  is  thicker,  especially  the  epidermal  layer,  and  therefore 
appears  cloudy  and  lustreless. 

THE  AURICLE 

#k 

The  auricle  projects  from  the  side  of  the  head  and  in  man  is  probably 
of  little  use.  The  auricle  is  made  up  of  an  irregular  framework  of  yellow 
elastic  fibrocartilage  covered  with  perichondrium  and  skin.  The 
cartilage  does  not  extend  into  the  lobule.  Generally  concave  externally 
with  its  upper  and  posterior  edges  rolled  in,  forming  the  helix.  Every 
concavity  is  represented  on  the  other  side  by  a  convexity  and  vice  versa. 
The  skin  over  the  outer  part  is  firmly  adherent  to  the  perichondrium 
by  elastic  fibers,  while  on  the  internal  side  the  skin  is  loose  with  con- 
siderable fatty  tissue  beneath  the  epidermis. 


THE    PRINCIPLES    AND    PRACTICE   OF   OTOLOGY 


The  posterior  line  of  insertion  is  along  the  squamomastoid  suture, 
and  thus  the  inferior  part  of  the  insertion  approaches  the  inferior  wall 
of  the  external  auditory  meatus.  The  linea  temporalis  is  about  on  a 
level  with  the  upper  border  of  the  concha,  which  is  formed  by  the  lower 
arm  of  the  forked  portion  of  the  anthelix.  In  operations  on  the  infant 
temporal  bone  the  insertion  of  the  auricle  and  its  fibrocartilaginous 
canal  serve  as  important  landmarks  in  making  the  first  incision  and  in 
locating  the  tympanomastoid  duct  (antrum).  At  birth  the  exit  of  the 
facial  from  its  bony  canal  is  close  beneath  the  lower  part  of  the  insertion 
of  the  auricle. 


Helix 


Crura  of  anthelicis 


Fossa  triangularis 

Tuberculum  auricula; 

Darwin's  tubercle 


Scapha 

f  cymba 

Concha  J  concha: 
auriculae  j  cavum 

[  conchic 


Anthelix 


Sulcus  auriculas  posterior 


Crus  helicis 

Tuberculum  supratragicum 

Tragus 

Meatus  acusticus  externus 


Inrisura  intertragica 


Antitragus 


Lobulus  auriculae 


FIG.  33. — RIGHT  AURICLE.     (Nomenclature  after  Spalteholz.) 

For  the  names  of  the  different  ridges,  concavities,  and  incisures  the 
student  is  referred  to  the  illustration  of  the  auricle  (Fig.  33) .  These  parts 
are  important  only  in  locating  exactly  the  position  of  a  wen  or  other 
pathologic  process.  The  cartilage  of  the  auricle  extends  into  the 
external  auditory  meatus  to  help  form  its  fibrocartilaginous  canal. 
Near  the  concha  the  cartilage  is  lacking  on  the  upper  wall  and  on  the 
upper  part  of  the  posterior  wall  of  the  auditory  canal;  the  cartilage  then 
tapers  down  to  a  flat  piece  attached  to  the  inferior  wall  of  the  osseous 
canal.  In  the  anterior  wall  of  this  cartilage  are  two  slits  called  the 
incisures  of  Santorini  (see  Fig.  i).  Through  these  slits  pus  may  make 
its  way  from  the  external  auditory  canal  or  from  infections  of  the  parotid 
gland  to  the  auditory  canal.  The  fascia  covering  the  parotid  gland  is 
wanting  in  this  region,  as  well  as  a  small  area  in  relation  to  the  tonsils, 
which  gives  a  possible  route  of  infection  from  the  external  auditory 
canal  to  the  throat. 


ANATOMY   OF   THE   TEMPORAL    BONE 


THE  EXTERNAL  OSSEOUS  CANAL 

The  external  osseous  canal  is  developed  after  birth  (Fig.  34).  The 
anterior  wall,  the  inferior  wall,  and  the  lower  portion  of  the  pos- 
terior wall  are  developed  from  the  tympanic  ring  (Fig.  35).  The 
upper  portion  of  the  posterior  wall  and  the  superior  wall  or  roof  are 
developed  from  the  squamous '  portion  of  the  temporal  bone.  At  the 
age  of  three  years  the  development  is  so  much  advanced  that  the  canal 
resembles  "the  adult  type  (Fig.  36).  A  small  dehiscence  is  found  in 
the  anterior  wall,  commonly  up  to  the  sixth  year  of  life.  Sometimes 
through  lack  of  development  the  dehiscence  persists  and  becomes  a 


7  8  pion 


FIG.  34. — TEMPORAL  BONE  AT  BIRTH. 
(Warren  Museum,  Harvard  Medical  School.) 

i,  Line  of  linea  temporalis;  2,  lid  over  tympanomastoid  duct;  3,  notch  of  Rivinus;  4,  zygoma;  5,  line 
of  squamopetrosal  fissure ;  6,  petrous  bone ;  7,  mastoid  tubercle ;  8,  stylomastoid  foramen ;  o,  annulus  tym- 
panicus;  10,  posterior  tubercle;  n,  anterior  tubercle. 

possible  pus  channel  for  infection  to  pass  from  the  auditory  canal  to 
the  articulation  of  the  jaw  (Fig.  37).  The  superior  wall  is  the 
shortest  of  the  four  walls.  Above,  the  superior  wall  is  made  up  of 
smooth  cortical  bone,  then  comes  a  thin  or  thick  layer  of  diploe,  and 
then  the  harder  inner  layer  lining  the  middle  fossa.  In  the  adult 
the  thickness  of  the  bone  between  the  upper  wall  of  the  osseous  canal 
and  the  middle  fossa  of  the  brain  varies  between  2  and  14  mm.  in  thick- 
ness. The  space  between  these  two  bony  layers  may  be  taken  up  by 
pneumatic  cells  which  communicate  with  the  zygoma  and  the  attic  of 
the  tympanic  cavity.  The  thicker  this  wall  separating  the  osseous 
canal  from  the  brain  cavity,  the  higher  the  attic  becomes,  so  that  in  the 
case  of  a  chronic  suppurative  otitis  media  with  loss  of  ossicles  the 


THE   PRINCIPLES    AND   PRACTICE    OF   OTOLOGY 


Squamoi>etrosal 
suture 


Anterior  tympanic 
tubercle 


Dehiscence 


Posterior  tympanic  tubercle 

FIG.  35. — DEVELOPMENT  OF  OSSEOUS  CANAL. 

Child  eighteen  months  old.     (Warren  Museum,  Harvard  Medical  School.) 

thickness  of  this  wall  may  be  judged  by  the  aural  probe.     The  inner 
portion  of  the  upper  wall  sometimes  shuts  off  a  direct  view  of  the  vestib- 


'  Notch  of  Rivinus         Zygoma 


Mastoid  process 


•  Developmental 
^j       dehiscence 


FIG.  36. — DEVELOPMENT  OF  OSSEOUS  CANAL. 
Child  four  years  old.     (Warren  Museum,  Harvard  Medical  School.) 

ular  window.  Above  this  inner  portion  is  the  epitympanum  or  attic, 
containing  the  head  of  the  malleus,  articulating  with  the  body  of  the 
incus  (see  Fig.  i). 


ANATOMY   OF   THE   TEMPORAL    BONE 


43 


The  posterior  wall  of  the  external  auditory  canal  is  in  relation  to 
the  mastoid  cells.  This  wall  may  be  paper  thin  to  5  mm.  in  thickness. 
The  descending  portion  of  the  facial  canal  is  in  relation  to  the  inner 
part  of  the  posterior  wall  and  has  been  named  by  the  surgeon  the  facial 
ridge.  Rarely  the  sigmoid  sinus  comes  very  close  to  this  wall.  The 
antrum  or  tympanomastoid  duct  lies  above  and  posterior  to  the  inner 
part  of  the  external  auditory  osseous  meatus.  Small  canaliculi  contain- 
«ig  blood-vessels  make  their  way  from  the  tympanomastoid  duct  to  the 
up^r  posterior  part  of  the  osseous  meatus,  close  to  the  drum  membrane, 
and  itNs  due  to  these  vessels  that  inflammation  is  carried  from  the 


Tubercle    External  auditory  osseous  canal 


Tympanic  plate      ;  Dehiscence 

Styloid  process 

FIG.  37. — DEHISCENCE  OF  TYMPANCM  PLATE  IN  ADULT. 
Pus  channel  to  articulation  of  jaw  and  parotid  gland. 

antrum  to  the  upper  posterior  part  of  the  canal  and  manifests  itself  by 
redness  and  bulging  in  any  acute  disease  of  the  tympanomastoid  duct. 

The  inferior  wall  is  generally  composed  of  compact  bone,  rarely 
containing  pneumatic  cells.  This  wall  is  rarely  in  relation  to  the  jugular 
bulb  in  that  portion  nearest  the  drum.  The  descending  portion  of  the 
facial  canal  is  at  a  depth  equal  to  about  half  the  length  of  this  inferior 
wall.  The  parotid  gland  is  in  relation  to  the  under  surface  of  this 
inferior  wall. 

The  anterior  wall  is  behind  the  condyle  of  the  lower  jaw  and  is  in 
relation  to  the  parotid  gland.  This  wall  may  be  paper  thin  or,  through 
lack  of  development,  it  may  be  perforated. 


44 


THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


A  sharp  instrument  or  probe  carried  along  the  junction  of  the  an- 
terior and  superior  walls  of  the  auditory  canal  in  a  direction  parallel 
to  the  bone  would  pierce  the  drum  membrane  and  tegmen  tympani 
posterior  to  the  horizontal  portion  of  the  carotid  artery  and  above  the 
opening  of  the  Eustachian  tube,  into  the  middle  cranial  fossa. 

THE  DRUM  MEMBRANE 

The  drum  membrane  lies  at  the  end  of  the  osseous  auditory  canal 
and  forms  the  external  wall  of  the  tympanic  cavity.  Since  the  anterior 
wall  of  the  external  auditory  canal  is  longer  and  extends  further  inward 
than  the  posterior  wall  the  drum  membrane  is  given  a  declination  of 


'19 


'27 


19        17 


FIG.  38.— THE  DRUM-HEAD  AND  TYMPANIC  OSSICLES  (Schematic.) 

i.  Anterior  boundary  fold;  2,  short  process  of  malleus;  3,  superior  fold;  4,  arteria  manubrium  mallei; 
5,  posterior  boundary  fold ;  6,  branch  of  deep  auricular  artery ;  7,  anterior  pouch  of  tympanic  membrane ;  8, 
posterior  pouch  of  tympanic  membrane ;  g,  long  process  of  incus ;  10,  stapes;  1 1 ,  ten  Jon  of  stapedius  muscle ; 
12,  chorda  tympani;  13,  anastomosis  of  arteria  manubrii  mallei  with  peripheral  system  of  blood-vessels ;  14, 
fenestra  cochlea; ;  15,  bulb  of  jugular  vein ;  16,  cone  of  light ;  17,  tympanic  cells ;  18,  posterior  fold ;  19,  umbo; 
20,  posterior  ligament  of  incus;  21,  superior  ligament  of  incus;  22,  superior  ligament  of  malleus;  23,  lateral 
fold  of  incus;  24,  lateral  fold  of  malleus;  25,  external  ligament  of  malleus;  26,  anterior  ligament  of  malleus; 
27,  peripheral  system  of  blood-vessels ;  28,  tegmen  tympani ;  29,  threshold  of  antrum.  (Briihl  and  Politzer.) 

50  degrees.  Since  the  inferior  wall  is  longer  than  the  superior  wall, 
the  inferior  pole  lies  further  inward  and  the  drum  membrane  is  given 
an  inclination  of  about  45  degrees.  Between  the  lower  pole  and  the 
inferior  wall  of  the  external  auditory  meatus  is  the  external  auditory 
sinus,  where  small  foreign  bodies  often  lodge  and  where  water  gives 


ANATOMY  OF  THE  TEMPORAL  BONE 


45 


the  sensation  of  a  bubble  in  the  ear.  The  drum  is  not  a  plane  surface, 
but  indrawn  like  a  funnel,  the  umbo  forming  the  apex.  The  drum 
membrane  is  inserted  in  a  small  groove  called  the  annulus  tympanicus, 
except  at  the  upper  part  of  the  membrane,  where  the  drum  is  attached 
to  the  squama  in  the  incisura  Rivini.  The  size  of  the  drum  membrane 
varies;  it  is  about  8  mm.  wide  and  9  mm.  high,  and  normally  about 
-j^  mm.  thick.  In  the  upper  anterior  part  there  is  a  yellowish-white  pro- 
tuberance, the  short  process  of  the  malleus,  and  from  this  protuberance 
running  downward  and  slightly  backward  is  the  handle  of  the  malleus 
ending  in  a  spatula-like  end,  called  the  umbo.  For  convenience  of 
description  the  drum  membrane  is  divided  into  quadrants.  The 


Mastoid  fossa 
(Bezold) 


Spine  of  suprameatus 
Zygoma 


Sheet  of  paper  on 
which  landmarks 
of  drum  membrane 
are  drawn 


Small  mastoid 
process 


FIG.  39. — ADULT  TEMPORAL  BONE  SECTIONED  so  THAT  CCT  PASSES  THROUGH  ANNULUS  TYMPANICUS. 

Cut  shows  piece  of  bond  paper  interposed.     Phantom  used  to  teach  student  to  incise  drum  membrane  (Wales). 

(See  Transactions  oj  American  Olological  Society,  1906.) 

anatomic  quadrants  vary  greatly  from  the  pathologic  quadrants.1  A 
line  drawn  through  the  short  process  and  umbo  and  another  straight 
line  at  right  angles  to  this  passing  through  the  umbo  divides  the  drum 
membrane  into  four  parts— an  anterior  upper,  an  anterior  lower,  a 
posterior  upper,  and  a  posterior  lower  quadrant  (Fig.  38).  The  anterior 
lower  quadrant  is  the  smallest  anatomic  quadrant,  the  posterior  upper 
quadrant  is  the  largest  anatomic  quadrant.  Behind  the  anterior  upper 
quadrant  lies  the  opening  into  the  Eustachian  tube,  the  canal  for  the 
tensor  tympani,  and  the  anterior  mucous  pouch  of  the  drum.  Behind 

1Passow,  "Transactions  of  the  German  Otological  Society,"  1906,  p.  203. 


40  THE  PRINCIPLES  AND  PRACTICE  OF  OTOLOGY 

the  anterior  lower  quadrant  lies  the  carotid  canal.  Behind  the  posterior 
upper  quadrant  is  the  long  process  of  the  incus,  the  stapes  in  the  vestib- 
ular  window,  the  pyramid  containing  the  stapedius  muscle,  the  chorda 
tympani  nerve,  and  the  posterior  mucous  pocket  of  the  drum  membrane. 
Behind  the  posterior  lower  quadrant  is  the  niche  to  the  cochlea  window 
and  the  bulb  of  the  jugular  vein.  Beneath  ShrapnelPs  membrane  is 
the  neck  of  the  malleus  and  Prussak's  space. 

The  membrana  tympani  consists  of  three  layers,  an  outer  cutaneous, 
a  middle  fibrinous,  and  an  inner  mucous  layer.  The  membrana  flaccida 
or  ShrapnelPs  membrane  consists  of  two  layers,  an  outer  cutaneous 
and  an  inner  mucous  layer. 


FIG.  39  (a). — INFANT  SKULL.  FIG.  39  (b). — ADULT  SKULL. 

Note,  position  of  annulus  tympanicus  in  Fig.  39  (a)  and  compare  with  adult  in  Fig.  39  (b)  :  a,  Annulus  tym- 
panicus ;  b,  upper  border,  notch  of  Rivinus  ;  c,  sphenoid  sinus ;  d,  probe  in  basilar  process  of  occipital  bone ; 
e,  probe ;  /,  condyle  fenestrated  ;  g,  carotid  canal ;  h,  facial  canal ;  i,  sigmoid  sinus ;  /,  jugular  fossa.  (War- 
ren Museum,  Harvard  Medical  School.) 

The  epithelial  layer  of  the  drum  membrane  is  made  up  of  layers 
of  flat  epithelium  with  cylindric  cells  in  the  deepest  layers.  The  epithe- 
lial layer  contains  blood-vessels  and  nerves.  The  fibrous  layer  consists 
of  an  outer  radiating  layer  and  an  inner  circular  layer  poor  in  elastic 
tissue-fibers.  The. mucous  layer  consists  of  simple  cuboidal  epithelium. 
This  layer -as  "it  passes  from'the  drum  to  the  tympanic  cavity  becomes 
higher  and-  on:  the  floor  of . the  tympanic  cavity  the  cells  are  ciliated. 
The  drum  membrane  of  the  infant  has  the  same  relative  position  as 
in  the  adult  and  is  not  more  •  horizontal.  This  can  be  seen  by  com- 
parison (Randall)  in  Fig.  39  (a)  and  Fig.  39  (b). 


ANATOMY   OF   THE   TEMPORAL   BONE 


THE  OSSICLES 

There  are  three  ossicles — the  malleus,  the  incus,  and  the  stapes. 
The  stapes  lies  in  the  vestibular  window,  the  malleus  lies  on  the  drum 
membrane;  between  the  stapes  and  the  malleus  is  the  incus.  The 
malleus  presents  a  head  lying  behind  the  membrana  flaccida  and  a 
handle  which  lies  in  the  drum  membrane.  Behind  the  head  of  the 


Head  of  malleu 

Neck  of  malleus 

Short  process  •'' 

Processus  gracilis  or  long'' 
process 

Handle  of  malleus 


—  Head 

—  Articulation  surface 

Articular  surface 

""-  Short  process 


Han-lie 


FIG.  40. — THE  RIGHT  MALLEUS.     (Spalteholz.) 

malleus  there  is  a  figure-of-eight  articulation  of  the  incus.  The  malleus 
(Fig.  40)  has  a  tooth-like  process  which  locks  with  the  incus  when  the 
drum  is  pushed  inward  and  unlocks  when  the  drum  is  pushed  outward. 
Anteriorly,  the  neck  of  the  malleus  presents  a  long  process,  the  remains  of 
Meckel's  cartilage.  Outwardly  the  short  process  at  the  beginning  of 


Body  of  incus_; 
Short  process  — 


Articular  surface 

i  Body  of  incus 


Short  process 


Articular  surface 
Articular  surface  *• 
Long  process I 


FIG.  41.— THE  RIGHT  INCUS.     (Spalteholz.) 

the  handle  projects  prominently.  Opposite  and  on  the  inner  aspect 
of  the  malleus  there  is  a  rough  spot  for  the  attachment  of  the  tendon 
of  the  tensor  tympani  muscle. 

The  incus  has  somewhat  the  appearance  of  a  tooth ;  its  head  articu- 
lates with  the  head  of  the  malleus  (Fig.  41).  A  short  process  rests  in 
the  fossa  incudis,  attached  by  a  ligament.  Its  long  process  articulates 


48 


THE   PRINCIPLES   AND   PRACTICE   OF    OTOLOGY 


with  the  stapes.  This  process  is  nearly  parallel  to  the  handle  of  the 
malleus  and  is  often  seen  through  the  normal  or  atrophied  drum  mem- 
brane. 

The  stapes  (Fig.  42)  or  stirrup   consists  of  a  foot-plate   which  is 
attached  by  an  annular  ligament  into  the  vestibular  window  (Fig.  43). 


61 


lead  of  stupes 
-Sulcus 
—Posterior  limb 


Base  Base 

FIG.  42. — THE  RIGHT  STAPES.     (Spalteholz.) 

From  the  foot-plate  two  arms  or  crurae  arise  and  join  (Fig.  44),  form- 
ing a  neck  which  slightly  swells  to  form  a  head.  The  stapedius  muscle, 
lying  in  the  pyramid,  takes  origin  along  the  ascending  part  of  the 
facial  canal  (Fig.  45).  The  muscle  is  about  5  mm.  long  and  is  attached 
to  the  neck  of  the  stapes  by  a  small  ligament.  The  tensor  tympani  is 


Cartilai 
Annular  ligament 


Bone  of  stapes 


t'iG.  43. — PORTION  OF  ANNULAR  LIGAMENT.     OSTEOPOROSIS.     (Prepared  by  Wales.) 

the  antagonist  to  the  stapedius  muscle  and  is  four  times  as  long  as  that 
muscle,  lying  in  the  canalis  musculotubarius. 

Supporting  the  ossicles  in  the  tympanic  cavity  there  are  five  liga- 
ments (see  Fig.  i): 

Anterior  ligament  of  malleus,  superior  ligament  of  malleus,  and  the 


ANATOMY  OF  THE  TEMPORAL  BONE 

Facial  nerve 


49 


Pneumatic  bone  cavities 


Scala  vestibuli 


Ampulla  showing 
crista  of  semi- 
circular canal 


rura  of  stapes 


Scala  tympani 


Cochlear  window  membrane 
FIG.  44. — VERTICAL  SECTION  THROUGH  LEFT  TEMPORAL  BONE.     (Prepared  by  Wales.) 

lateral  ligament  of  the  malleus,  which  passes  to  the  upper  edge  of  the 
incisura  Rivini.     The  superior  ligament  of  the  incus,  passing  to  the 


Facial  nerve 


Stapedius  muscle 


Head  of  stapes.. 


Dehiscence 


FIG.  45. — VERTICAL  SECTION  SHOWING  RELATION  OF  STAPEDIU  ;  MUSCLE  TO  FACIAL  NERVE. 

tegmen  tympani,  and  the  ligament  of  the  short  process  of  the  incus, 
passing  to  the  fossa  incudis  on  the  floor  of  the  antrum.  Folds  of  mucous 
membrane  are  thrown  around  the  ossicles,  their  muscles,  ligaments, 

4 


THE    PRINCIPLES   AND   PRACTICE    OF   OTOLOGY 


and  the  chorda  tympani  nerve  forming  pockets  which  are  the  means  of 
guiding  pus  to  certain  parts  of  the  drum  membrane  (see  Fig.  38). 
Three  of  these  pouches  are  in  contact  with  the  drum  membrane, 
namely,  the  anterior  pouch,  the  posterior  pouch,  and  Prussak's  space. 

THE  EUSTACHIAN  TUBE 

The  Eustachian  tube  connects  the  tympanic  cavity  with  the  naso- 
pharynx and  is  about  36  mm.  long.  Its  lumen  toward  the  tympanic 
end  is  about  4  mm.  high  and  toward  the  pharyngeal  end  about  5  mm. 
One-third  of  the  tube  is  osseous,  that  part  nearest  the  tympanic  cavity, 
and  two-thirds  cartilaginomembranous;  the  isthmus  joins  both  these 
parts  and  is  about  2  mm.  broad.  The  tube  runs  downward,  inward, 

Pneumatic  cell 
Tenth   Ninth    Seventh    Eighth    (/         Inferior  petrosal 


Lateral  sinus     nerve     nerve       nerve      nerve 


Sigmoid  sinus 


sinus  Carotid  artery 


Eustachian 
tube 


Internal   jug- 
ular vein 


Jtl: 


Carotid  arterv 


FIG.  46. — VERTICAL  SECTION  TO  SHOW  RELATION  OF  EUSTACHIAN  TUBE  TO  CAROTID  ARTERY  AND  MIDDLE 

MENINGEAL  ARTERY. 
Berlin  Anatomical  Institute.     (Specimen  of  Wales.) 

and  forward  and  its  ostium  pharyngeum  lies  25  mm.  deeper  than  the 
ostium  tympani  tubae.  Note  the  relation  of  the  tube  to  the  internal 
carotid  artery  and  the  middle  meningeal  artery  (Fig.  46). 

The  membranocartilaginous  portion  consists  of  a  medial  carti- 
laginous part  and  an  outer  part  made  up  of  connective  tissue.  The 
tube  passes  between  the  palatine  muscles  and  the  tensor  palati  externus 
in  front,  while  the  levator  palati  muscle  is  internal  and  behind. 

The  levator  palati  muscle  arises  from  the  lower  and  outer  part  of 
the  Eustachian  cartilage  and  from  the  rough,  under  side  of  the  apex 
of  the  petrous  bone  in  front  of  the  carotid  canal.  It  descends  inward 
and  slightly  forward  to  be  attached  to  the  soft  palate.  This  muscle  is 
supplied  by  a  branch  of  the  facial  nerve,  conveyed  to  the  muscle  through 


ANATOMY   OF   THE   TEMPORAL    BONE  51 

the  great  superficial  petrosal,  MeckeFs  ganglion,  and  the  posterior 
palatine  nerves. 

The  tensor  palati  lies  anterior  and  external,  separated  from  the 
levator  palati  muscle  by  the  pharyngeal  aponeurosis.  It  arises  from  the 
linear  outer  margin  of  the  scaphoid  fossa,  from  the  spine  of  the  sphenoid, 
and  from  the  outer  surface  and  lower  border  of  the  Eustachian  cartilage. 
As  it  descends  its  fibers  converge  to  unite  in  a  tendon  which  winds 
round  the  hamular  process,  from  without  inward,  passing  thence  horizon- 
tally to  be  inserted  into  the  transverse  ridge  on  the  posterior  surface  of 
the  palate  plate  and  into  the  palatine  aponeurosis.  Beneath  the  tendon 
there  is  a  small  bursa  over  the  hamular  process.  The  tensor  palati 
muscle  is  supplied  by  the  inferior  maxillary  division  of  the  fifth  nerve. 

The  walls  of  the  tube  normally  are  in  contact  except  during  swallow- 
ing and  in  some  pathologic  conditions.  The  mucous  membrane  of  the 
Eustachian  tube  consists  of  three  layers:  first,  the  ciliated  epithelium; 
second,  the  adenoid  layer;  third,  the  glandular  layer.  All  these  layers 
are  separated  from  one  another  by  elastic  fiber  layers.  The  cartilage 
of  the  tube  is  elastic  cartilage  and  contains  clefts  and  holes. 

THE  OSSEOUS  LABYRINTH 

The  three  semicircular  canals  with  their  ampullae  form  a  part  of 
the  labyrinth.  The  osseous  semicircular  canals  surround  a  thin-walled 
membranous  structure  called  the  membranous  semicircular  canals. 
The  osseous  canal  consists  of  compact  bone.  Its  lumen  is  from  i^-  to  2 
mm.  and  on  cross-section  has  an  elliptic  form.  The  position  of  the 
semicircular  canals  in  the  petrous  portion  of  the  temporal  bone  to  the 
rest  of  the  labyrinth  is  posterior  and  lateral,  while  the  anterior  part 
forms  the  cochlea,  which  is  mostly  medial.  Each  of  the  three  semi- 
circular canals  originates  with  an  elliptic  enlargement,  the  so-called 
osseous  ampullae,  from  the  walls  of  the  vestibule,  and  after  making  nearly 
a  whole  circular  turn  they  re-enter  the  vestibule.  These  three  semi- 
circular canals  unite  with  the  vestibule  by  five  openings,  since  the  cerebral 
and  cerebellar  canals  join  and  enter  by  a  canal  in  common.  The  planes 
of  the  semicircular  canals  are  nearly  perpendicular  to  each  other.  They 
are  called  the  cerebral  or  superior  vertical  (frontal)  semicircular  canal, 
the  cerebellar  or  posterior  vertical  (sagittal),  and  the  tympanomastoid 
or  external  lateral  (horizontal)  semicircular  canal  (Fig.  47). 

The  cerebral  canal  is  perpendicular  to  the  superior  border  of  the 
petrous  bone  and  the  hard  bony  wall  of  its  convexity  comes  to  the 
surface  of  the  cerebral  face  of  the  petrous  bone,  forming  the  eminentia 
arcuata.  The  cerebellar  canal  lies  deeper  than  the  cerebral  canal 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


and  its  convexity  is  directed  backward.  Its  plane  lies  nearly  parallel 
to  the  cerebellar  face  of  the  petrous  bone.  The  tympanomastoid  canal 
is  also  directed  backward  and  its  outer  arm  forms  a  prominence  on  the 
tympano-antral  face  of  the  petrous  bone  and  lies  somewhat  parallel, 
upward  and  backward  from  the  facial  canal.  The  prominence  of  this 
canal  is  seen  on  opening  the  mastoid  antrum  and  is  an  important  guide 
to  the  facial  nerve.  Here,  too,  is  the  most  common  point  of  caries  in 
disease  of  the  vestibule,  and  inspection  under  a  strong  artificial  light 
is  essential.  The  length  of  the  loops  of  the  semicircular  canals  varies. 
The  cerebellar  is  the  longest,  the  tympanomastoid  is  the  shortest.  The 


Ampulla  of  cerebral  semicircular  canal 

;     Ampulla  of  tympanomastoid  semicircular  canal 
Foot  plate  of  stapes 

Superior  ligament  of  malleus 
Head  of  malleus 
i  External  ligament 


Schrapnell's  membrane 


Tendon  of  tensor  tympani 
muscle 

Handle  of  malleus 


Tympanic  membrane 


Cerebral  semicircular  canal 


Common  crus  of  cerebral  and  I 
cerebellar  semicircular  canals  I 


Nonampullary  opening  of  cere- 
bral and  cerebellar  semicir- 
cular canals 

Nonampullary  opening  of 
tympanomastoid  semicir- 
cular canal 


Cerebellar  semicircular  canal         :        Long  process  of  incus 

Ampulla  of  cerebellar  semicircular  canal 

FIG.  47. — SCHEMATIC  VIEW  OF  VESTIBULE  AND  TYMPANIC  PORTION  OF  MIDDLE  EAR. 

inner  surface  of  the  osseous  semicircular  canal  is  covered  with  a  perios- 
teal  lining  or  endosteum.  The  space  between  the  membranous  semi- 
circular canal  and  the  endosteum  is  called  the  perilymphatic  space. 
This  space  communicates  with  the  labyrinth  and  to  the  posterior  cere- 
bellar fossa  by  means  of  the  aqueductus  cochlea  to  the  subarachnoid 
space. 

The  delicate  membranous  semicircular  canal  is  filled  with  endolymph. 
The  shape  and  position  of  the  three  membranous  semicircular  canals 
with  their  ampullae  corresponds  to  the  osseous  semicircular  canal. 
The  average  diameter  of  the  membranous  semicircular  canal  is  about 
one-third  the  diameter  of  the  osseous  semicircular  canal  (Fig.  48). 
The  membranous  semicircular  canal  is  attached  to  the  outer  peripheral 


ANATOMY  OF  THE  TEMPORAL  BONE 


53 


wall  of  the  osseous  semicircular  canal.  From  the  free  circumference 
bordering  on  the  perilymphatic  space  are  numerous  connective-tissue 
bands  or  ligaments  which  are  attached  to  the  endosteum  of  the  osseous 
semicircular  canal.  The  membranous  ampullae  are  from  2  to  2\  mm. 


Endolymph 


FIG.  48. — RELATIVE  SIZE  OF  MEMBRANOUS  SEMICIRCULAR  CANAL  TO  OSSEOUS  SEMICIRCULAR  CANAL. 

(Prepared  by  Wales.) 

in  diameter  in  the  direction  of  the  semicircular  canal  and  about  \\  mm. 
perpendicular  to  that  direction.  In  a  small  groove  on  the  floor  of  the 
ampullae,  called  the  sulcus  transversus,  the  ampullae  nerve  enters  the 
crista  acustica. 

THE  VESTIBULE 

The  vestibule  lies  between  the  cochlea  and  the  semicircular  canals, 
the  cochlea  anterior  and  the  semicircular  canals  posterior.  The  vesti- 
bule may  be  compared  to  a  cube.  It  has  six  surfaces  nearly  perpen- 
dicular to  each  other,  but  not  of  equal  area.  The  upper  side  or  roof 
has  a  smaller  surface  than  the  base  or  any  of  the  four  sides.  One  of 
the  four  sides  is  in  about  the  same  plane  as  the  cerebral  (anterior  vertical) 
semicircular  canal.  It  is,  therefore,  at  right  angles  to  the  superior 
border  of  the  petrous  bone.  This  surface  looks  forward  and  inward 
and  Sondermann  calls  it  the  sellar  wall  of  the  vestibule  because  it  looks 
toward  the  sella  turcica.  The  wall  running  parallel  to  this  in  the  direc- 
tion of  the  mastoid  is  called  the  mastoid  wall.  Perpendicular  to  these 
two  surfaces,  in  the  long  direction  of  the  pyramid,  looking  internal  and 


54 


THE   PRINCIPLES    AND   PRACTICE   OF    OTOLOGY 


posterior,  is  the  posterior, medial  wall.     The  other  wall,  looking  external 
and  anterior,  is  called  the  anterolatcral  surface  or  wall. 

The  sellar  wall  separates  the  internal  auditory  meatus  from  the 
vestibule.  The  recessus  sphericus  lies  below  and  posterior  medially 
from  the  recessus  ellipticus,  and  also  lies  somewhat  deeper  in  the  bone 
in  the  direction  of  the  sella  turcica  toward  the  apex  of  the  pyramid. 
The  recessus  sphericus  is  separated  from  the  recessus  ellipticus  by  the 
crista  vestibuli  which  projects  into  the  vestibule  from  the  middle  of  the 
sellar  surface,  having  a  horizontal  direction.  The  anterolateral  end  of 
the  crista  thickens  and  forms  a  swelling  like  a  pyramid,  called  pyramis 
cristae.  The  posteromedial  end  is  forked,  surrounding  the  fossula 


Ampulla  of  cerebellar  semicircular  canal 


Internal  auditory  meatus 


Pelvis  ovalis 


Tympanic  cavity 


Scala  vestibuli 


FIG.  49. — HORIZONTAL  SECTION  SHOWING  FLOOR  OF  VESTIBULE  AND  RELATION  OF  COCHLEA  TO  INTERNAL 

AUDITORY  MEATUS. 

sulciformis.  This  fossula  closes  the  vestibular  end  of  the  aqueductus 
vestibuli,  a  definite  canal  taken  up  by  the  ductus  endolymphaticus 
communis.  The  fossula  sinks  deeper  into  the  sellar  wall  to  the  corner 
where  the  sellar,  the  posteromedial,  and  the  upper  wall  or  roof  of  the 
vestibule  meet.  From  there  the  aqueductus  vestibuli  is  directed  up 
and  posterior  in  the  substance  of  the  pyramid  crossing  the  posteromedial 
arm  of  the  cerebellar  semicircular  canal  and  ending  in  the  apertura 
aqueductus  vestibuli  on  the  cerebellar  surface  of  the  pyramid.  There 
the  ductus  endolymphaticus  swells  out  into  the  saccus  endolymphaticus. 
The  floor  or  lower  wall  of  the  vestibule  corresponds  to  the  medial 
wall  of  the  tympanic  cavity  and  lies  more  horizontal  than  vertical;  in 


ANATOMY  OF  THE  TEMPORAL  BONE  55 

other  words,  the  tympanic  cavity  undermines  the  floor  of  the  vestibule 
(Fig.  49).  In  the  floor  is  the  vestibular  window.  This  window  extends 
the  whole  length  of  the  floor  from  the  sellar  to  the  mastoid  wall.  Toward 
the  sellar  wall  it  is  nearer  the  anterolateral  wall  than  the  posteromedial 
wall,  below  the  place  where  the  recessus  sphericus  and  ellipticus  come 
together.  Toward  the  mastoid  end  the  vestibular  window  is  in  the 
floor  midway  between  the  two  openings  of  the  external  lateral  semi- 
circular canal.  Its  greatest  extent  is,  therefore,  somewhat  oblique 
to  the  long  axis  of  the  pyramid  in  the  floor  of  the  vestibule.  Toward 
the  sellar  wall  is  the  beginning  of  the  scala  vestibuli,  called  by  Sonder- 
mann  canalis  vestibuli  cochlearis.  The  lower  edge  of  the  recessus 
sphericus  is  undermined  by  the  scala  vestibuli. 

The  posteromedial  wall  of  the  vestibule  contains  the  ampulla  end 
of  the  cerebellar  semicircular  canal. 

The  upper  wall  or  roof  of  the  vestibule  contains  the  entrance  of  the 
crus  commune  near  its  posteromedial  edge. 

The  anterolateral  wall  contains  the  ampulla  end  of  the  cerebral 
semicircular  canal. 

The  mastoid  wall  is  perpendicular  to  the  long  axis  of  the  pyramid 
and  contains  the  ampulla  and  non-ampulla  ends  of  the  external  lateral 

semicircular  canal. 

THE  COCHLEA 

The  cochlea  is  cone  shaped  and  surrounded  by  hard  bone.  Its 
axis  is  nearly  horizontal.  Its  base  lies  against  the  anterior  part  of  the 
fundus  of  the  internal  auditory  meatus.  Its  lower  anterior  wall  is  in 
relation  to  the  first  knee  of  the  internal  carotid  artery  and  its  rounded  apex 
is  directed  toward  the  canal  for  the  tensor  tympani  muscle  (Fig.  50). 
In  the  adult  the  apex  is  4  to  4  ^  mm.  anterior  to  the  anterior  border  of 
the  vestibular  window.  The  modiolus  of  the  cochlea  extends  from 
the  base  to  the  apex,  it  is  cone  shaped  and  made  up  of  spongy  bone, 
around  which  the  spiral  cone  makes  two  and  three-quarter  turns 
(Fig.  51).  From  the  modiolus  a  plate  of  bone  projects  (spiral  osseous 
lamina)  into  the  spiral  canal,  a  distance  of  little  more  than  one-half  its 
diameter,  dividing  the  space  into  two  compartments.  The  modiolus  is 
filled  with  small  canals  which  run  parallel  to  the  axis;  these  canals  are 
arranged  at  the  base  of  the  modiolus  in  a  spiral  manner  and  end  at  the 
base  of  the  osseous  spiral  lamina,  where  they  open  into  the  spiral  canal 
of  the  modiolus  (canal  of  Rosenthal)  for  the  spiral  ganglia. 

The  secondary  osseous  spiral  lamina  begins  near  the  mastoid  end  of 
the  vestibular  window  in  a  broad  bony  plate  above  the  cochlea  window 
and  runs  along,  gradually  growing  smaller,  till  it  vanishes,  ending  at  a 


THE   PRINCIPLES   AND   PRACTICE    OF   OTOLOGY 


Small  superficial  j-ctrosal  nerve 
Eustachian  tube      !     Tensor  tympani  muscle 


Condyle  of  jaw 
Parotid  gland 


Osseous  spiral  lamina 

Facial  nerve 

Internal  auditory  meatus 

Auditory  nerve 


Dotted  line  represents  jugular 
bulb 


FIG.  50. — VERTICAL  SECTION  SHOWING  RELATION  OF  APEX  or  MODIOLUS  TO  TENSOR  TYMPANI  MUSCLE. 
Berlin  Anatomical  Institute.     (Prepared  by  Wales.) 

point  about  one-half  the  length  of  the  first  turn  of  the  cochlea.     The 
osseous  spiral  lamina  begins  on  the   floor  of   the  vestibule  near  the 

Great  superficial  petrosil  nerve 

Artery  through  fossa  subarcuata 
i       Cerebral  semicircular  canal 

Tympanomastoid  semicircular  canal 
Facial  nerve  •          Cerebellar  semicircular  canal 


Sigmoid  portion  of 
transverse  sinus 

Branch  of  mastoid  vein 

Common    duct    of 

mastoid  vein 
Branch  of  mastoid  vein 


Vestibule 


Internal  jugular  vein 
Carotid  artery 


Facial  nerve        Large  pneumatic  cell  in  tip  of 
mastoid  process 

FIG.  51. — CORROSION  OF  ADULT  RIGHT  TEMPORAL  BONE. 
Medial  view.     (Prepared  by  Wales.) 

recessus  cochlearis,  starting  in  a  direction  parallel  to  the  axis  of  the 
modiolus,  turning  while  in  the  vestibule  to  become  perpendicular  to  the 
axis  of  the  modiolus,  and  ends  at  the  hamulus.  Between  the  concave 


ANATOMY  OF  THE  TEMPORAL  BONE 


57 


edge  of  the  hamulus  and  the  lamina  modioli  the  end  of  the  cochlea  duct 
forms  a  round  opening,  called  the  heliotrema,  where  the  scala  vestibuli 
and  scala  tympani  join,  having  been  separated  the  whole  length  of  the 
bony  spiral  lamina  by  the  cochlea  duct.  The  cleft  between  the  osseous 
spiral  lamina  and  the  secondary  spiral  lamina  in  the  vestibule  gradually 
broadens  as  the  secondary  osseous  spiral  lamina  grows  smaller. 

MEMBRANOUS  LABYRINTH 

The  membranous  labyrinth  is  formed  by  a  system  of  hollow  spaces 
containing  a  fluid  poor  in  albumin,  called  endolymph;  these  hollow 
spaces  are  lined  with  epithelium  and  contain  the  nerve-endings  of  the 

External  auditory  meatus          Great  superficial  petrosal  nerve 


Tensor  tympani 
muscle 


Sigmoid    portion   of 
transverse  sinus 


Common  mastoid 
vein 


Eustachian  tube 

Pneumatic  cells  ex- 
ternal to  Eustn- 
chian  tube 

Carotid  artery 


Large  cell  mastoid  tip        Facial  nerve  Into  jugular  vein 

FIG.  52. — CORROSION  OF  ADULT  RIGHT  TEMPORAL  BONE  (LATERAL  VIEW).    (Prepared  by  Wales.) 


Sensory  epithelium 


Endolymph 


Nerve  fibers 
FIG.  53. — HUMAN  MACULA  ACUSTICA.    (Wales.) 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


Bone 


Perilymphatic  space 


Membranous  semi- 
circular canal 


Endolymphatic 
space 


Sensory  epithelium 


filaments 


FIG.  54. — CRISTA  ACUSTICA  OF  ADULT.    (AMPULLA.) 
Boston  City  Hospital.     (Wales.) 


eighth  nerve.  The  membranous  labyrinth  lies  within  the  bony 
labyrinth,  appearing  much  smaller  in  cross-section,  and  attached  here 
and  there  by  connective-tissue  strands.  Around  its  delicate  structure 


Sensory  epithelium 


FIG.  55. — HUMAN  CRISTA  ACUSTICA. 
Higher  magnification  of  sensory  epithelium  of  Fig.  54.     (Prepared  by  Wales.) 

there  is  a  space  filled  with  a  fluid  also  poor  in  albumin,  called  perilymph. 
This  space  is  lined  with  endothelium.  In  the  bony  vestibule  there 
are  two  vestibular  sacs,  the  utricle  and  the  saccule.  The  utricle 


ANATOMY  OF  THE  TEMPORAL  BONE  59 

lies  in  the  recessus  ellipticus  of  the  vestibule,  where  it  is  held  to  the 
bone  by  connective  tissue,  and  the  utriculus  nerve  enters  the  macula 
cribrosa  superior.  The  fibers  of  the  utriculus  nerve  end  in  the  macula 
acustica  utriculi  (Fig.  53).  The  membranous  semicircular  canals  end 
in  five  openings.  They  lie  on  the  convex  side  of  the  bony  canals  and 
are  about  one-third  the  size  of  the  bony  canals.  Through  the  sulcus 
ampullaris  in  the  ampullae  the  ampullaris  nerve  ends  in  the  crista  ampul- 
laris  (Figs.  54  and  55).  The  sacculus  is  smaller  than  the  utriculus, 
lies  in  the  recessus  sphericus  of  the  vestibule,  and  is  fastened  to  the 
bone  by  connective  tissue  and  fibers  of  the  saccularis  nerve  coming 
through  the  macula  cribrosa  media.  Its  lower  end  narrows  to  the 

Scala  vestibuli 
Membrana  tectoria  _^A^fe^^l      J^jJs^^^^pirul  ganglion 


Reissner's  membrane 

Vas  prominens 
Ductus  cochleari 
Tunnel  of  Corti 


Spiral  ligament  of 
cochlea 


Crista  spiralis 
^^   'Nerve  fibers 
Scala  tympani 

Canal  of  Rosenthal         Modiolus 
FIG.  56. — COCHLEA  OF  ADULT.     (Prepared  by  Wales.) 

ductus  reuniens,  which  joins  the  ductus  cochlearis.  The  saccularis 
nerve  ends  in  the  macula  acustica  sacculi.  The  utricle  is  joined  to 
the  saccule  through  the  forked  end  of  the  ductus  endolymphaticus. 

The  membranous  labyrinth  is  formed  by  the  ductus  cochlearis, 
which  begins  in  the  recessus  cochlearis  of  the  vestibule,  the  caecum 
vestibulare,  and  ends  blindly  in  the  cupula,  to  help  form  the  helicotrema. 
On  cross-section  it  is  for  the  most  part  triangular,  its  outer  wall  uniting 
with  the  thickened  periosteum  of  the  inner  surface  of  the  osseous  cochlear 
canal.  Its  base  connects  with  the  osseous  spiral  lamina  and  the  free 
edge  of  the  spiral  ligament  on  the  outer  wall;  it  consists  of  a  fibrous 
connective  tissue,  the  lamina  basilaris,  which  supports  the  organ  of 
Corti  (Fig.  56). 


6o 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


ANATOMY 

VASCULAR  AND  NERVOUS  SUPPLY  OF  THE  ORGAN  OF  HEARING,  COPIED  FROM 
BRUHL-POLITZER'S  Atlas  and  Epitome  oj  Otology : 


PART  SUPPLIED. 

VESSEL.                                      COURSE. 

Auricle  

Helix,  tragus,  lobe.            Anterior    auricular    artery    (superficial  In  front  of  the  ear. 

temporal). 

Greater  part  of  the  au-  Posterior     auricular     artery     (external    Posterior       auricular 

ride.                                   carotid),        perforating        branches.       fossa    and    through 

Veins  empty  into  the  superficial  tern-       the  cartilage. 

poral  and  external  jugular  veins. 

Cartilaginous.     Anterior  Anterior  auricular  artery.                           Entrance        through 

wall.                                                                                  junction  of  the  car- 

External       auditory  , 

Posterior   Posterior  auricular  artery.                              tilaginous  and  bony 

wall.                                                                                  auditory  canal. 

Bony.                                   Deep  auricular   artery   (internal   max- 

illary). 

Stratum  cutaneum.              Anteria  manubrii  mallei  (deep  auricu-  Annulus       tendineus 

lor).                                                               and    stratum  cuta- 

neum  behind    ma- 

rl ubrium        mallei. 

Drum-head 

Radial  anastomosis. 

Stratum  mucosum.              Anterior    tympanic    (internal    maxil-  Through       Glaserian 

lary)    perforating    branches    (anas-       fissure  and  stratum 

tomosis      between       stratum    cuta-       cutaneum       behind 

neum  and  stratum  mucosum).                   manubrium    mallei. 

Roof.                                       Branches  of    the    middle  meningeal          Radial  anastomosis. 

artery  (internal  maxillary). 

Eustachian  tube  .  . 

Floor.                                      Basilar  branch  of  ascending  pharyn-     Petrosquamous  fissure. 
geal  artery  (external  carotid)  and 

vidian  artery  (superior  palatine). 

Mastoid  cells.                   Mastoid  branches   (stylomastoid  ar-  From    the     Fallopian 

tery).                                                          canal. 

Mastoid  process 

Attic  and  antrum.             Branches  of    the    middle  meningeal  Petrosquamous        fis- 
artery.     Veins  empty  into  the  pos-       sure. 

terior  auricular  vein  and  transverse 

sinus. 

Tympanic  cavity  .  .  . 

Anterior  portion.               Caroticotympanic   branch  of   external  Caroticotympanic 

carotid  artery.                                             canaliculi. 

Tympanic  cavity.  . 

Anterior     ligament     of  Anterior     tympanic     artery    (internal  Glaserian  fissure. 

malleus.                              maxillary  artery). 

Posterior  portion.               Posterior   tympanic   artery  (stylomas-  Canal       for      chorda 

toid).                                                            tympani. 

Stapedius  muscle.               Stapedic  (stylomastoid  artery).              Pyramidal   eminence. 

Stapes.                                 Branch  to  the  stapes  (stylomastoid  ar-  From    the     Fallopian 

tery).     Anastomosis  of  stylomastoid       canal. 

artery     with     superficial     petrosal 

branch. 

Tensor  tympani  muscle.    Branch  to  tensor  tympani  (middle  me-  Spurious  hiatus. 

Tympanic  cavity  .  .  . 

ningeal  artery). 
Upper  portion.                    Superior  tympanic  artery  (middle  me-  Roof  of  tubes. 

ningeal).  Superficial  petrosal  branch 

(middle  meningeal). 
Lower  portion.                    Inferior    tympanic    artery  (ascending  Apertura  superius  ca- 

pharyngeal).                                             naliculi  tympanici. 

Wall  of  promontory  and    Branches     that     communicate     with  Vascular    perforations 

endosteum    of    laby-        branches  of    the    internal  auditory      in          promontorial 

rinth.                                      artery.     Veins    empty  into  middle       wall  (Politzer). 

meningeal  and  deep  auricular  veins. 

Osseous    semicircular        Arteria  subarcuata.                                   Fossa  subarcuata. 

canal  capsule.                 Internal  auditory  artery  (basilar).          Porus     acusticus     in- 

ternum. 

Membranous      semicir-  Vestibular   artery    (internal    auditory).  With  vestibular  nerve. 

cular  canals,  utricle, 
and  saccule,  espec- 
ially the  cristae  and 
maculae  acusticae. 

Cochlea  nerve,  spiral 

Labyrinth ganglia  osseous  spiral 

lamina,  scala  vestibuli, 
periosteum  of  walls  of 
scalae,  spiral  ligament. 
I  Utricle  and  saccule,  coch- 
lea. 

Semicircular  canals, 
utricle. 

Cochlea, 


Cochlear  artery  (internal  auditory).         With  cochlear  nerve. 

Venous  blood  flows 
off  in  scala  tympani 
(vas  spirale). 


Internal  auditory  vein. 
Vena  aqueductus  vestibuli. 
Vena  aqueductus  cochleae. 


Into  inferior  petrosal 

sinus. 
Into  transverse  sinus. 

Into  bulb  of   jugular 
vein. 


'£T 


nr 


FIG.  57. — FOR  DESCRIPTION,  SEE  PAGES  61  AND  62. 


ANATOMY  OF  THE  TEMPORAL  BONE  6 1 

PART  DRAINED  LYMPH-GLAND.  LYMPH-VESSEL. 

Lymph     channels.       Cavum  conchae,  external  Lymph-gland  in  front  of  tragus.  Lower    anterior    lym- 

auditory  canal.  phatic  vessel. 

Triangular  fossa,   ante-  Highest  mastoid  gland.  Upper    anterior    lym- 

rior  surface  of  helix.  phatic  vessel. 

Helix,     antihelix,     pos-  Mastoid  and  cervical  glands.  Posterior      lymphatic 

terior  surface.  vessel. 

Lobe,  auditory  canal.       Parotid  glands.  Posterior      lymphatic 

vessel. 
Drum-head,      tympanic  Mastoid  glands  on  sternocleidomastoid. 

cavity. 

Labyrinth.  Aquaeductus     cochleae 

in  subarachnoid. 

NERVE  SUPPLY.  MOTOR.  SENSORY. 

Extrinsic     muscles  Posterior    auricular    nerve    (facial  Muscle  of  the  ear.  Auricularis    magnus    nerve    (third 
of  the  ear.  nerve),  cervical  nerve). 

Anterior    auricular    nerve     (right  Auditory  canal.       Auriculotemporal       nerve       (fifth 

temporal     nerve — seventh).  nerve). 

Stapedius     muscle.  Stapedius   nerve   (seventh   nerve).   Cartilaginous.          Nerve    of    the  external    auditory 

meatus  {auriculotemporal  nerve). 

Tensor      tympanic  Tensor  tympanic  nerve  (otic  gan-  Bony        posterior  Auricular  nerve,  vagus  nerve  (tym- 
muscle.  glion  and  fifth  nerve).  wall.  panomastoid  fissure). 

Seventh  nerve  through  great  super-  Drum-head.  Nervi  membranae  tympani  (nerve 

ncial  petrosal  nerve  (from  genie-  of  the  external  auditory  meatus). 

ulate  ganglion  through  spurious  Tympanic  cavity.    Plexus  tympanicus. 
hiatus,   anterior  lacerated   fora-  Eustachian  tube,      (a)  Caroticotympanic  branch  (les- 
raen,    vidian   canal  to  the  nasal  ser  deep  petrosal  nerve).    In- 

ganglion,  pterygopalatine  nerves).  ternal  carotid  plexus  of  sym- 

pathetic. 

Tensor  veli  muscle.  Otic  ganglion,  fifth  nerve.  (6)  Tympanic  (Jacobson's)  nerve 

Retrahens  tubae.       Pharyngeal  plexus,  vagus  nerve.  from    petrous    ganglion. 

Ninth    nerve     through     infe- 

Vaso  constrictors  of  Sympathetic  nerve.  rior   aperture   and   superior 

the  entire  ear.  tympanic     canal     to     small 

superficial     petrosal     nerve. 

Secretory.  Anastomosis      with     eighth 

Taste    of    anterior  Chorda  tympani  (seventh  nerve) ;  nerve   through   the  anterior 

half   of    tongue ;       fibers  of  the  chorda  tympani  are  lacerated  foramen  to  the  otic 

salivary  secretion       joined  to  the  seventh  nerve  by  ganglion  of  the  fifth  nerve 

of     submaxillary       the  intermediate  portion  of  the  and  parotid, 

and      sublingual       ninth   and   extend   through   the 
glands.  apertura   canaliculi   chorda   be- 

tween hammer  and  incus  to  folds 
of  drum-head  ;  through  the  Gla- 
serian  fissure  to  the  lingual  nerve 
(fifth  nerve). 


FIG.  57. — SCHEMATIC  VIEW  OF  THE  UNION  OF  THE  NERVES  OF  THE  MIDDLE  EAR  WITH 
THE  SURROUNDING  NERVES  (BRUHL  AND  POLITZER,  AFTER  LANDUS). 

1.  External  maxillary  artery.  7.  Pterygoid  promontory.  12.  Promontory. 

2.  Submaxillary  gland.  8.  Parotid  gland.  13.  Bulb  of  jugular  vein. 

3.  Sublingual  gland.  9.  Cerebral  surface  of  the  pyramid.  14.  Stapedius  muscle. 

4.  Tongue.  10.  Tensor  tympani  muscle.  15.  Tympanomastoid  duct 

5.  Uvula.  u.  Carotid.  (antrum). 

6.  Upper  jaw.  16.  Eighth  nerve. 

Green — Fifth  nerve.  Yellow — Seventh  nerve  (solely  motor). 

(a)  Gasserian  ganglion.  (q)  Seventh  nerve  in  the  porus  acusticus  internus. 

(6)  Ophthalmic  branch  (sensory).  (r)  Intermediary  nerve  (glossopharyngeal  nerve). 

(i  )  Maxillary  branch  (sensory  and  motor).     Major  (s)  Geniculate  ganglion  and  great  superficial  petrosai 
superficial  petrosal  nerve  yellow.                                        to  the  sphenopalatine  ganglion  (e)  and  the  post- 

(d)  Root  to.  palatine  to  the  muscles  of  the  palate  (5)  motor. 

(e)  Sphenopalatine  ganglion.  (/)  Anastomosis  to  the  lesser  superficial  petrosal  nerve. 
(/)  Sphenopalatine  nerve  (sensory).  (u)  Stapedius  nerve. 

(g)    Postinferior  nasal  nerve  (sensory).                             (v)  Chorda  tympani,  continuation  of  the  intermediary 

(h)    Mandibular  branch  (sensory  and  motor).  nerve   to  the   lingual   nerve    and    submaxillary 

(i)    Root  to.  gland  (2)  to  the 

(/)    Otic  ganglion.                                                             (w)  Sublingual  ganglion  and  ps,  the  lingual  running  to 

(k)    Branch  from  the  otic  ganglion  to  the  tensor  veli  the  tongue  (p)  (anterior    half)  and  sublingual 

palatine  muscle  (motor).  gland  (3). 

(/)    Branch  of  the  otic  ganglion  to  the  tensor  tympani  (.v)  Posterior  auricular  nerve. 

muscle  (motor).                                                        (y)  Anastomosis  with  the  ninth  nerve. 

(m)  Mastoid  branch  to  the  chorda  tympani.                   (2)  End  branch  (per  anserinus  major). 
(»)   Auriculotemporal  nerve  (secretory). 
(o)    Lingual  nerve. 
(P)    Lingual  branches  (sensory). 


62  THE   PRINCIPLES    AND   PRACTICE   OF   OTOLOGY 

White — Tenth  nerve. 

A.  Jugular  ganglion. 

B.  Auricular  nerve  to  the  tenth  (sensory).     Anastomosis  with  the  seventh,  where  the  two  cross  each  other. 

C.  Ganglion  nodosum. 

D.  Pharyngeal  rami  (motor). 

Red — Ninth  nerve.  Blue — Sympathetic  nerve. 

(a)  Petrosal  ganglion.  I.,   II.,   III.,   IV.     Four   cervical    ntrves   (cervical 

(ft)  Tympanic  nerve  (Jacobson's  nerve).  plexus), 

(y)  Caroticotympanic  nerve  (deep  lesser  petrosal).  V.  Superior  cervical  ganglion. 

(&)  Superficial  lesser  petrosal  nerve  (continuation  of  VI.  Anastomosis  to  the  tenth  nerve, 
the  tympanic  nerve),  to  the  ganglion  (k)  and  a  VII.  Anastomosis  to  the  ninth  nerve, 
branch.  VIII.  Pharyngeal  branches. 

(«)   For  the  auriculotemporal  nerve  (parotid).  IX.  Internal  carotid  nerve  (plexum). 

(»))  Pharyngeal  branch  (sensory).  X.  Anastomosis  with  the  petrosal  ganglion. 

(#)  Lingual  branch  (taste  posterior  half  of  tongue).  XI.  Lesser   deep   petrosal   nerve    (to   the   tympanic 

nerve). 

XII.  Great  deep  petrosal  nerve  (Vidian  nerve).  To 
the  sphenopalatine  ganglion  (e),  and  from 
here  to  the  nose  (glands). 

XIII.  Union  of  the  otic  ganglion  to  the  meningeal  plexus. 

XIV.  Union  of  the  sublingual  ganglion  to  the  maxillary 

plexus. 


CHAPTER  II 
PHYSIOLOGY  OF  THE  ORGAN  OF  HEARING 

VERY  little  is  actually  known  about  the  function  of  hearing.  The 
physiology  of  the  internal  ear  is  wholly  theoretic,  and  theory  is  but 
another  term  for  ignorance.  To  understand  these  theories  it  is  essential 
to  have  a  knowledge  of  the  physics  of  sound  and  also  of  the  minute 
anatomy  of  the  brain  and  temporal  bone. 

In  the  infant  hearing  is  the  last  sense  to  awaken.  W.  Preyer  made 
observations  on  his  own  child.  For  the  first  three  days  of  the  infant's 
life  he  could  get  no  sure  reaction  to  sound,  but  on  the  fourth  day  he  was 
convinced  that  his  child  was  not  deaf.  In  the  second  week  there  was  no 
doubt  that  the  infant  was  soothed  by  the  sound  of  his  voice.1  Loud 
noises  do  not  seem  to  frighten  the  infant  for  the  first  two  or  three  days 
after  birth.  The  reason  for  this  deafness  is  probably  due  to  the  fact 
that  the  mucous  membrane  of  the  tympanic  cavity  contains  embryonic 
tissue.  This  embryonic  tissue  forms  a  pad  or  cushion  which  quite 
fills  the  tympanic  cavity.  The  remaining  space  is  filled  with  amniotic 
fluid  and  macerated  epithelium.  As  the  embryonic  tissue  in  the  mucous 
membrane  and  the  fluid  in  the  tympanic  cavity  are  absorbed,  hearing 
takes  place. 

The  tensor  tympani  muscle  changes  the  tension  of  the  drum  mem- 
brane and  the  chain  of  ossicles,  serving  to  accommodate,  so  that  sound- 
waves of  small  intensity  may  be  heard,  and  probably  helping  to  dampen 
sound-waves  of  great  intensity,  thus  acting  as  a  protecting  as  well  as 
accommodative  device.  The  stapedius  muscle  raises  the  anterior  end 
of  the  foot-plate  out  of  the  vestibular  window  when  the  muscle  contracts, 
and  is  probably  accommodative  in  its  action  also.  The  stapedius  muscle 
is  antagonistic  to  the  tensor  tympani  muscle. 

It  is  known  that  the  semicircular  canals  and  the  vestibule  act  as 
organs  of  equilibration,  and  yet,  when  the  vestibular  apparatus  is  com- 
pletely destroyed,  which  condition  is  found  in  some  deaf-mutes,  the 
eyes,  the  muscles,  and  joints  seem  to  be  sufficient  to  maintain  equilibrium, 
with  the  advantage  that  rotary  movements  do  not  cause  vertigo  or 
nystagmus. 

1  W.  Preyer,  "Die  Seele  des  Kindes,"  1905. 

63 


64  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

The  arrangement  of  the  cochlea  is  ideal  for  compactness;  its  thick 
bony  capsule  protects  its  delicate  nerve-endings  and,  furthermore,  these 
nerve-endings  are  suspended  in  fluid  within  a  cavity,  all  tending  to 
avoid  irritation  of  any  sort  but  sound  irritation.  If  the  organ  of  Corti 
were  surrounded  by  air  it  would  constantly  be  irritated,  possibly  by 
heat,  cold,  humidity,  dust,  and  chemical  vapors.  If  the  cochlea  were 
filled  with  connective  tissue,  could  sound-waves  be  perceived?  Such 
conditions  have  been  found  in  deaf-mutes.  Again,  in  this  field  of 
speculation,  do  sound-waves  travel  by  way  of  the  drum  membrane, 
ossicles,  or  vestibule  to  the  sensory  epithelium  in  the  cochlear  duct 
(Helmholtz),  or  do  sound-waves  go  directly  to  the  sensory  epithelium 
by  bone  conduction?  (Zimmermann.) 

The  drum  membrane  is  largely  protective,  probably  as  well  as 
accommodative,  through  the  tympanic  muscles.  The  drum  membrane 
prevents  the  entrance  of  water,  bacteria,  and  insects  into  the  tympanic 
cavity  and,  probably  more  important,  the  drum  membrane  prevents 
the  varying  atmospheric  air  from  drying  its  delicate  mucous  membrane. 
Only  the  warmed,  moistened,  and  cleansed  air  from  the  respiratory 
tract  can  normally  enter  the  tympanic  cavity  by  way  of  the  Eustachian 
tube.  Pathologic  conditions,  such  as  thickenings,  calcifications,  atro- 
phies, healed  perforations,  and  even  adhesions  are  not  necessarily 
indicative  of  diminished  hearing  power,  so  far  as  we  are  able  to  test  by 
whispered  and  conversational  voice  and  by  the  tuning-forks. 

The  auricle  is  a  rudimentary  organ  in  man  and  the  least  it  does 
is  to  protect  the  side  of  the  head  from  a  fall  or  blow.  In  many  animals 
the  auricles  serve  to  protect  the  organ  of  hearing  from  loud  sounds  and 
may  be  directed  toward  the  source  of  the  sound,  but  this  act  may  be  a 
reflex  action  after  the  attention  is  called  to  a  moving  object  by  the  sense 
of  smell  or  sight.  The  horse  pricks  up  its  ears  at  the  sight  of  food  and 
the  ears  lie  back  when  in  anger.  It  might  as  well  be  said  that  the 
auricle  is  an  appendage  for  expression.  In  man  the  movement  of  the 
auricle  is  a  rare  and  useless  accomplishment.  Individuals  with  large 
auricles  hear  no  better  than  those  with  small  auricles.  It  is  said  that 
the  hearing  is  normal  in  individuals  who  have  lost  their  auricles.  No 
convincing  proof  has  yet  been  presented  which  would  show  that  the  auri- 
cle is  of  any  importance  whatever. 

Physiologists,  as  a  rule,  omit  the  study  of  the  physiology  of  the  organ 
of  hearing,  because  experiments  on  this  organ  are  most  difficult.  It 
is  not  possible  to  observe  the  separate  complex  parts  in  action  and 
record  their  movements.  It  is  easy  to  fill  in  the  space  allotted  to  physi- 
ology with  physics  and  anatomy  and  a  few  theories.  Most  aurists  are 


PHYSIOLOGY   OF   THE   ORGAN  OF   HEARING  65 

not  physicists  or  physiologists  and  thus  the  physiology  of  the  organ  of 
hearing  has  been  slighted.  New  facts  are,  however,  rapidly  accumu- 
lating and  the  functions  of  the  hearing  apparatus  will  probably  be  solved 
through  the  study  of  pathology  and  comparative  anatomy. 

The  following  is  abstracted  from  the  writings  of  Alfred  Denker : l 
"  Sound-waves  can  be  carried  from  a  sounding  body  to  the  end  apparatus 
of  the  eighth  nerve  by  way  of  the  air  or  when  the  sounding  body  is 
brought  in  contact  with  the  body  through  bone-conduction. 

"Conduction  of  Sound-waves. — There  are  two  ways  to  consider 
in  which  sound-waves  are  conducted  through  the  air:  First,  the  sound- 
waves are  transferred  to  the  drum  membrane  and  from  here,  either 
through  the  ossicular  chain  or  through  the  air  in  the  tympanic  cavity, 
to  the  labyrinth  and  the  endings  of  the  eighth  nerve;  second,  the  sound- 
waves go  from  the  air  to  the  head  bones  and  from  these  are  conducted 
either  directly  to  the  contents  of  the  labyrinth  or  from  the  head  bones 
through  interposition  of  the  ossicular  chain  to  the  internal  ear. 

"  Johannes  Miiller  has  proved  experimentally  that  vibrations  trav- 
eling from  the  air  to  a  stretched  membrane,  and  from  here  to  a  freely 
movable  solid  part,  and  from  this  transferred  to  fluid,  are  communicated 
to  the  fluid  much  stronger  than  when  the  vibrations  go  from  a  stretched 
membrane  to  air  and  from  air  to  fluid ;  in  other  words,  the  same  air-waves 
act  much  more  intensely  transmitted  by  way  of  the  ossicular  chain  to 
the  vestibular  window  than  they  are  by  way  of  the  drum  membrane 
through  the  air  of  the  tympanic  cavity  to  the  cochlea  window. 

"  Bezold  considers  that  the  function  of  the  ossicular  chain  is  to  admit 
the  lower  part  of  the  tone  scale  from  the  air.  Any  interruption  of  the 
free  movement  of  this  chain  of  ossicles  causes  lowering  in  the  hearing 
distance  for  whispered  speech.  Helmholtz,  in  his  work  on  The  Mechan- 
ics of  the  Ossicles  and  the  Membrana  Tympani,  has  clearly  shown  that 
the  ossicular  chain  is  a  powerful  lever  apparatus  which  conducts  great 
movements  of  little  force  and  converts  them  into  slight  movements  of 
great  force. 

"  Zimmermann  believes  that  sound-waves  can  travel  directly  from 
the  air  to  the  labyrinth  without  the  cooperation  of  the  ossicular  chain, 
part  through  the  cochlea  window  and  part  through  the  promontory. 
He  believes  that  in  the  conduction  of  sound-waves  we  do  not  have 
to  deal  with  molar  movement,  but  with  molecular  movements. 

"  As  to  the  conduction  of  sound-waves  to  the  labyrinth,  Bonning  has 
published  interesting  investigations  from  observations  in  comparative 
anatomy.  He  found  that  the  temporal  bone  of  the  whale  was  not  in 

1  Alfred  Denker,  "  Die  Otosklerosis." 
5 


66  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

close  bony  union  with  the  bones  of  the  skull,  but  was  joined  by  connective 
tissue.  He  believes  a  direct  conduction  from  the  head  bones  to  the 
labyrinth  is  excluded,  and  his  opinion  is  that  sound-waves  can  only 
be  conducted  through  cooperation  of  the  ossicular  chain. 

"  Against  the  theory  that  the  ossicular  chain  has  not  a  sound-conduct- 
ing function,  but  only  a  labyrinth  pressure-regulating  function,  is  the  fact 
that  when  the  labyrinth  is  intact  there  is  complete  deafness  when  there 
is  complete  fixation  of  the  stapes  in  the  vestibular  window  and  closure 
of  the  cochlea  window.  What  further  supports  the  acceptance  that 
the  membrana  tympani  and  the  ossicular  chain  have  a  sound-conducting 
function  is  the  fact  that  in  the  animal  series  the  development  of  the 
internal  ear  and  the  tympanic  cavity  apparatus  accompany  each  other. 

"  Bezold  reported  the  results  of  hearing  tests  of  4  cases  where  the 
labyrinth  was  lacking  on  one  side  and  normal  on  the  other.  In  these 
patients  there  was  created  a  natural  hearing  tube  through  the  empty 
tympanic  and  labyrinth  cavities  in  connection  with  the  external  auditory 
canal,  which  went  deep  into  the  skull,  nearly  reaching  the  healthy  laby- 
rinth. If,  now,  the  acceptation  that  sound-waves  can  be  transmitted 
through  the  bones  directly  to  the  labyrinth  is  correct,  then  the  sound- 
waves must  be  carried  from  the  walls  of  the  hollow  labyrinth  and  be 
perceived  by  the  labyrinth  on  the  sound  side.  The  tests  showed  that 
the  whole  lower  half  of  the  tone  scale  up  to  the  third  octave  was  not 
heard  even  when  the  tuning-fork  was  violently  struck  and  placed  in  the 
ear  where  the  labyrinth  was  lacking.  We  know  that  it  is  impossible 
to  occlude  the  perception  of  higher  tones  even  when  the  sound  ear  is 
tightly  closed  so  that  the  higher  tones  could  not  be  considered.  This 
positive  observation  is  against  the  acceptance  of  direct  bone  conduction 
of  sound-waves  and  we  know  that  without  the  ossicular  chain  the  hearing 
of  the  lower  tones  of  tuning-forks  up  to  the  third  octave  by  air  is,  on  the 
whole,  impossible. 

"  The  manner  by  which  sound-waves  are  communicated  to  the  laby- 
rinth from  direct  contact  with  the  bone  to  a  solid  swinging  body  has  not 
yet  been  solved. 

"The  Function  of  the  Intrinsic  Muscles  of  the  Ear.— Helmholtz 
showed  that  a  contraction  of  the  tensor  tympanic  muscle  caused  an 
inward  movement  of  the  umbo  and  at  the  same  time  an  inward  move- 
ment of  the  lenticular  process  of  the  long  arm  of  the  incus,  so  that  the 
foot-plate  of  the  stapes  was  pressed  into  the  vestibule. 

"  Tension  of  the  tendon  of  the  stapedius  muscle  causes  a  slight  inward 
movement  of  the  foot-plate  on  the  posterior  lower  periphery  of  the  ves- 
tibular window,  at  the  same  time  the  anterior  pole  and  its  upper  per- 


PHYSIOLOGY    OF   THE    ORGAN    OF    HEARING  67 

iphery,  on  account  of  its  broad  annular  ligament,  is  drawn  out  laterally. 
This  causes  a  lessening  of  the  labyrinthine  pressure. 

"  If  there  is  diminution  of  the  air-pressure  in  the  tympanic  cavity, 
such  as  occurs  in  catarrh  of  the  Eustachian  tube,  the  tensor  tympani 
predominates  and  the  foot-plate  of  the  stapes  is  pushed  inward.  Again, 
if  the  membrana  tympani  is  destroyed,  with  both  malleus  and  incus, 
then  the  stapedius  muscle  draws  the  foot-plate  outward.  Both  muscles, 
considered  by  their  action  on  the  foot-plate,  are  antagonistic.  If  both 
muscles  act  at  the  same  time,  the  contraction  of  the  tensor  tympani 
with  its  strong  inward  movement  and  the  contraction  of  the  stapedius 
muscle  with  its  outward  movement,  the  stapedius  muscle  must  exert 
a  stronger  tension  on  the  annular  ligament.  The  tensor  tympani 
muscle  has  the  function  of  stiffening  the  ossicles  of  the  sound-conducting 
apparatus.  Both  muscles  are  to  be  considered  as  accommodative 
muscles,  for  they  are  capable  of  the  same  common  function,  in  so  ad- 
justing the  membrana  tympani  and  foot-plate  through  different  degrees 
of  tension  that  perception  is  favored  for  respective  sound-waves. 

"  Ostmann  proved  on  the  hearing  organ  of  dogs  that  in  the  act  of 
listening-  a  contraction  of  the  stapedius  muscle  took  place.  Persons 
who  have  fixation  of  the  sound-conducting  apparatus  with  lessened 
capability  of  action  of  the  tensor  tympani  and  stapedius  muscles  fre- 
quently complain  that  when  in  the  company  of  several  people  speak- 
ing at  once  they  have  great  difficulty  in  clearly  understanding  and  in 
isolating  a  single  voice.  Probably  both  muscles  take  part  in  this 
accommodation. 

"The  Organ  of  Corti. — The  end-organ  of  the  eighth  nerve,  or  organ 
of  Corti,  is  suspended  freely  in  fluid.  Helmholtz  knew  that  easily 
swinging  bodies  meeting  sound-waves  from  sound-producing  bodies 
were  made  to  swing.  This  sympathetic  swinging  is  called  resonance. 
Helmholtz  considered  the  organ  of  Corti  to  be  a  resonance  apparatus. 
He  still  further  found  it  was  necessary  to  have  a  great  series  of  resonators 
of  different  tones  and,  therefore,  of  different  sizes,  like  the  cords  of  a 
piano;  lastly,  the  internal  ear  must  be  capable  of  resolving  the  tone. 
At  first  it  was  thought  that  the  pillars  of  Corti  acted  as  resonators,  but 
Helmholtz  found  that  birds  and  crocodiles  had  no  pillars  of  Corti. 
Since  these  creatures  hear,  he  concluded  that  the  pillars  of  Corti  did  not 
act  as  resonators.  Then  Hensen  discovered  the  cords  of  the  basilar 
membrane  on  which  the  pillars  were  supported.  Near  the  base  of  the 
cochlea  these  cords  are  about  ^  mm.  long  and  they  gradually  increase 
till  at  the  apex,  wrhere  they  are  about  \  mm.  long.  The  number  of 
the  cords  is  from  15,000  to  25,000  and  must  be  capable  of  resolving 


68  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

from  15  to  20,000  vibrations.  Helmholtz  believed  that  the  basilar 
cords  were  the  resonating  part  of  the  organ  of  Corti.  Helmholtz's 
theory  of  sound  perception  is  as  follows:  Sound  is  resolved  into  its 
different  tones,  which  shake  the  basilar  cords  by  their  selective  resonance, 
and  through  the  swinging  of  the  cords  the  corresponding  hearing  cells 
are  affected.  The  stimulus  is  then  carried  to  the  brain  through  the 
cochlear  nerve  to  the  cortex  of  the  brain,  where  the  original  sound  is 
perceived  as  a  whole  through  associative  tract  activity." 


CHAPTER  III1 
BACTERIOLOGY  OF  THE  EAR 

INVESTIGATION  of  purulent  discharges  from  the  middle  ear  began 
simultaneously  with  modern  bacteriology.  Most  cultures  were  made 
from  one  to  thirty  days  following  perforation  of  the  drum  membrane. 
In  this  interval  of  time  the  middle-ear  secretions  could  not  only  be 
infected  by  micro-organisms  from  the  external  auditory  canal,  but 
also  secondary  infection  could  take  place  by  way  of  the  Eustachian 
tube.  Some  of  the  early  investigators  examined  the  pus  directly  after 
incising  the  drum,  others  after  spontaneous  rupture  of  the  drum  mem- 
brane. The  results  of  these  investigations  showed  that  the  diplococcus 
pneumoniae  of  Frankel  was  most  common;  next  and  most  frequent  the 
streptococcus  pyogenes,  and  lastly,  the  staphylococcus  (albus,  citreus, 
aureus).  Later  investigators  tried  to  disinfect  the  external  auditory 
canal  and  the  drum  membrane  The  external  auditory  canal  was  then 
aseptically  sealed  for  twenty-four  hours  and  if  found  sterile  the  drum 
was  incised  and  the  discharge  examined.  The  difficulties  in  technic 
are  many  and  it  is  because  of  these  difficulties  that  investigators  vary 
so  greatly  in  their  results.  Taking  cultures  at  the  time  of  operation 
on  acute  cases  of  mastoiditis  was  first  applied  by  Leutert.  The  technic 
at  post-mortem  examinations  is  not  so  difficult. 

Whether  the  healthy  tympanic  cavity  normally  contains  bacteria 
or  is  absolutely  devoid  of  germs  is  a  question.  Citelli,  Cohn,  Zaufal, 
Hasslauer,  Ernst,  and  others  maintain  that  the  normal  tympanic  cavity 
contains  pathogenic  bacteria  and  that  these  pathogenic  bacteria  are 
in  a  quiescent  stage  or  few  in  number,  and  become  active  only  when  the 
conditions  for  their  development  are  favorable.  Just  as  pathogenic 
bacteria  are  present  in  the  normal  throat,  for  example,  Klebs-Loffler 
bacillus  of  diphtheria  is  present  in  most  throats,  yet  the  individual  does 
not  necessarily  have  diphtheria,  so  the  middle-ear  cavity,  which  is  a 
prolongation  of  the  respiratory  tract,  may  contain  tubercle  bacilli  and 
yet  the  patient  may  not  have  tuberculosis  of  the  ear. 

On  the  other  hand,  Lannois,  S.  Weiss,  Preysing,  Stopple,  and  others 
assert  that  the  normal  tympanic  cavity  does  not  contain  pathogenic 

1  In  this  chapter  opinions  from  the  work  of  Dr.  Hasslauer  of  Nurnberg  are  freely 
quoted. 


70  THE    PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 

bacteria.  Lannois  and  S.  Weiss  made  experiments  on  animals,  while 
Preysing  made  his  observations  at  autopsy  on  the  human  body. 

If  the  middle  ear  contains  bacteria,  then  the  factors  which  would 
lower  the  vitality  of  the  organism,  allowing  the  bacteria  to  multiply, 
would  be  of  more  etiologic  importance  than  the  bacteria;  whereas,  if 
the  statement  of  Lannois  and  Preysing  be  accepted,  the  bacteria  are  of 
great  importance  etiologically.  In  either  case  bacteria  are  important 
and  are  present  in  every  inflammation,  whether  catarrhal  or  suppurative. 

How  may  bacteria  get  into  the  tympanic  cavity? 

(a)  By  way  of  the  external  auditory  canal  in  rupture  of  the  drum 
membrane  through  direct  or  indirect  traumatism.  Karl  Stopple  showed 
that  the  bacteria  in  the  external  auditory  canal  were  mostly  saprophytic 
and  not  the  same  composition  as  found  in  middle-ear  inflammation. 
Probably  infection  cannot  take  place  through  an  intact  drum  membrane. 
Secondary  infection  may  take  place  after  the  drum  membrane  is  incised. 
Sometimes  a  permanent  opening  remains  in  the  drum  membrane  after 
the  middle-ear  inflammation  has  subsided.  Here  a  new  infection  may 
take  place,  especially  if  water  is  introduced — in  washing  the  ears,  by 
use  of  the  syringe,  or  in  sea  bathing. 

(6)  Bacteria  may  enter  by  the  Eustachian  tube,  either  by  continuity 
or  they  may  be  forced  into  the  tympanic  cavity  by  sudden  interruption 
of  the  air  current  when  blowing  the  nose;  by  the  act  of  swallowing  when 
using  the  nasal  douche;  by  sniffing  fluids  into  the  nose  from  the  palm 
of  the  hand;  sometimes  in  sneezing,  in  vomiting,  or  in  paroxysms  of 
coughing.  Often  by  the  Valsalva  (or  auto-inflation),  sometimes  by  the 
Politzer  air-douche,  and  rarely  by  the  use  of  the  catheter.  The  presence 
of  postnasal  discharge,  of  acute  and  chronic  diseases  of  the  nasopharynx, 
of  hypertrophied  adenoid  tissue  or  tonsils  which  interfere  with  the 
function  of  the  Eustachian  tube,  paralysis  of  the  nerves  supplying  the 
muscles  of  the  tube,  and  sudden  loss  of  fatty  tissue,  as  in  typhoid  fever- 
all  these  factors  favor  infection  of  the  tympanic  cavity.  The  infection 
of  the  middle  ear  is  made  more  difficult  by  the  length  and  narrowness 
of  the  Eustachian  tube  and  by  the  downward  movement  of  its  ciliated 
epithelium;  also  by  the  presence  of  an  intact  epithelium  in  the  middle  ear. 

(c)  Bacteria  may  enter  the  tympanic  cavity  by  way  of  the  lymph 
and  blood-vessels,  as  Barnick  has  demonstrated  in  miliary  tuberculosis. 

(d)  Bacteria  may  enter  by  way  of  the  external  auditory  canal  in 
fracture  of  the  skull,  the  bacteria  entering  the  mastoid  cells  and  the 
infection  thus  spreading  to  all  parts  of  the  middle  ear. 

(e)  Bacteria  may  enter  from  the  cranial  cavity  by  way  of  the  laby- 
rinth, facial  canal,  or  petrosquamous  fissure. 


BACTERIOLOGY  OF   THE   EAR  7 1 

The  external  auditory  canal  contains  the  bacteria  commonly  found 
in  the  skin  (staphylococcus  albus)  and  the  bacteria  which  are  blown  or 
washed  in  from  without.  The  staphylococcus  is  the  most  common  and 
is  usually  the  cause  of  otitis  externa  circumscripta.  Smegma  bacilli 
and  other  acid-resisting  bacilli  non-pathogenic  in  character  may  be 
mistaken  for  tubercle  bacilli.  Individuals  with  lowered  vitality,  as  in 
rickets,  anemia,  or  diabetes,  are  more  liable  to  infection  of  the  external 
auditory  canal. 

Aural  discharges  generally  contain  two  or  three  varieties  of  pathogenic 
bacteria  and  occasionally  saprophytic  bacteria.  Occasionally  the 
pneumobacillus  of  Friedlander  is  found.  Etienne  found  it  5  times 
in  238  bacteriologic  examinations.  A  still  rarer  bacterium  is  the  bacillus 
pyocyaneus.  Kanthack  found  it  once  in  pure  culture.  Kossel  found 
the  bacillus  pyocyaneus  in  the  middle  ears  of  3  children  whose 
drum  membranes  were  intact,  once  in  pure  culture,  twice  together 
with  diplococci.  Gerber  found  the  bacillus  pyocyaneus  one  day  after 
incision  of  the  drum  membrane.  J.  Orne  Green  found  the  bacillus 
pyocyaneus  immediately  after  incision  in  3  cases.  Most  of  the  cases 
reported  show  a  mixed  infection  and  investigators  disagree  as  to  whether 
the  bacillus  pyocyaneus  can  cause  middle-ear  suppuration.  Kossel 
believes  it  is  pathogenic  for  infants,  but  not  for  adults.  Kanthack 
believes  it  acts  pathogenically  only  in  combination  with  other  pathogenic 
bacteria.  Pes  and  Gradenigo  assert  that  it  can  produce  a  general  as 
well  as  a  local  infection  of  the  organism.  A  further  proof  of  the  patho- 
genic nature  of  bacillus  pyocyaneus  is  brought  forth  by  Leutert,  who 
collected  4  cases  of  perichondritis  of  the  auricle  where  the  growth  showed 
a  pure  culture  of  the  bacillus  pyocyaneus.  Further,  Ruprecht  and 
Helmann  found  the  bacillus  pyocyaneus  in  pure  culture  as  the  cause 
of  a  case  of  otitis  externa  crouposa.  Preysing  asserts  that  there  is  no 
proof  that  the  bacillus  pyocyaneus  can  cause  otitis  media  in  infants. 

Professor  Korner  observed  5  cases  complicated  with  the  bacillus 
pyocyaneus  in  the  course  of  fifteen  years.  In  all  these  5  cases  the 
pyocyaneus  had  discolored  the  discharge  the  usual  green  color  before 
the  onset  of  perichondritis.  This  constant  association  of  green  pus 
with  perichondritis  suggested  that  the  latter  was  caused  by  the  bacillus 
pyocyaneus,  and  in  a  case  Korner  observed,  this  etiologic  connection 
was  confirmed. 

Otitis  media,  in  consequence  of  acute  infectious  diseases,  such  as 
scarlet  fever,  measles,  diphtheria,  influenza,  etc.,  is  designated  as  sec- 
ondary middle-ear  inflammation. 

Scarlet  Fever. — Marie  Raskin  made  the  first  bacteriologic  investi- 


72  THE   PRINCIPLES    AND    PRACTICE   OF   OTOLOGY 

gations  of  the  so-called  scarlet  fever  otitis;  then  followed  Wolf,  Blaxall, 
Pearce,  Zaufal,  Councilman,  Thomas,  and  others.  Marie  Raskin  and 
Leutert  speak  of  the  streptococcus  as  the  cause  of  scarlet  fever  otitis. 
The  otitis  does  not  come  on  late  in  the  disease,  as  in  many  cases  of 
secondary  otitis,  but  in  the  beginning  of  scarlet  fever  favored  by  the 
intense  throat  inflammation.  The  otitis  of  scarlet  fever  is,  therefore, 
considered  as  a  specific  disease  process.  The  streptococcus  of  scarlet 
fever  soon  loses  its  virulence  and  may  be  replaced  eventually  by  other 
bacteria.  Lewy  describes  a  destructive  early  form  of  scarlet  fever 
otitis.  Acute  middle-ear  suppuration  occurred  seven  days  before  the 
outbreak  of  the  exanthem  and  was  followed  rapidly  by  mastoiditis  with 
necrosis;  the  dura  mater  was  exposed  in  the  middle  and  posterior  cranial 
fossae.  Necrosis  of  the  posterior  wall  of  the  external  auditory  canal 
was  present  and  caries  of  the  ossicles  and  formation  of  a  fistula  leading 
into  the  tympano-antral  semicircular  canal  had  taken  place.  In  a  second 
case  the  middle-ear  inflammation  appeared  in  the  second  week  of  the 
disease,  with  caries  of  the  incus  and  necrosis  of  the  mastoid  process. 
In  the  beginning  of  the  disease,  even  on  the  second  or  third  day,  micro- 
organisms are  found  in  the  blood,  either  free  or  enclosed  in  the  leukocytes 
or  in  the  stroma  of  the  mucous  membrane,  and  occasionally  in  the  lymph- 
cells  of  the  connective  tissue.  These  micro-organisms  and  their  toxins 
cause  suppuration  and  rapid  destruction  of  the  soft  tissues  and  bone. 
Korner  believes  that  the  otitis  should  be  interpreted  as  a  symptom  of 
the  general  infection  and  divides  scarlet  fever  otitis  into  two  forms: 
the  early  destructive  form  and  the  much  milder  late  form,  the  latter 
appearing  in  the  first  stages  of  desquamation. 

Scarlet  Fever  with  Diphtheria. — In  scarlet  fever  with  diphtheria 
the  bacillus  of  diphtheria  does  not  appear  till  the  ear  affection  has 
existed  several  days.  Forbes  believes  it  must  be  a  secondary  invasion 
of  the  bacillus  of  diphtheria  after  a  true  scarlet  fever  otitis.  The  second- 
ary infection  is  brought  about  by  way  of  the  Eustachian  tube.  Forbes 
did  not  find  an  accompanying  throat  diphtheria  in  any  case,  but  recog- 
nized the  diphtheria  bacillus  in  the  discharge  32  times  out  of  40  cases 
of  post  scarlet  fever  otitis. 

Measles. — The  most  common  bacteriologic  finding  in  measles  has 
also  been  the  streptococcus.  Comparatively  little  investigation  has 
been  made  of  the  bacteria  found  in  the  otitis  accompanying  measles. 
Otitis  of  measles  does  not  appear  to  be  caused  by  a  specific  infection 
as  in  scarlet  fever,  but  as  a  local  sign  of  the  primary  disease.  The  gen- 
eral disease  brings  about  such  changes  of  the  mucous  membrane  of  the 
middle  ear  that  the  pathogenic  germs  in  the  middle  ear  obtain  a  favor- 


BACTERIOLOGY   OF  THE   EAR  73 

able  field  in  which  to  develop  their  activity.  In  100  cases  of  measles 
Xadoleczny  found  the  middle  ear  affected  in  59.5  per  cent.  Most  of 
the  cases  developed  within  the  second  week  of  the  disease.  In  measles 
a  specific  bacterial  excitant  is  even  less  established  than  in  scarlet  fever. 
Diphtheria. — Otitis  media  caused  by  Klebs-LofBer  bacillus  may 
be  divided  into  three  classes : 

1.  Primary  diphtheritic  inflammation  of  the  middle  ear,  which  is 
very  rare. 

2.  A  few  cases  in  which  the  bacillus  of  diphtheria  has  made  its 
way  from  the  throat  to  the  middle  ear. 

3.  The  most  common  form  is  the  secondary  middle-ear  infection 
which  accompanies  the  disease.     To  prove  the  presence  of  this  third 
form  Lommel  found  on  the  examination  of  24  children  dying  of  diph- 
theria only  one  normal  ear,  all  the  others  showed,  simple  middle-ear 
inflammation  with  serous  or  purulent  exudate.     Thus  Lommel  came 
to  the  conclusion  that  the  otitis  media  belongs  to  the  picture  of  a  diph- 
theritic disease  of  the  organ  of  respiration.     Lewin  also  states  that 
acute  otitis  media  often  accompanies  genuine  throat  diphtheria.     The 
aural  process  is  not  a  specific  one,  but  a  local  manifestation  of  the 
disease  as  a  whole.     The  otitis  media  is  not  commonly  caused  by  direct 
transmission.     Nearly  all  observers  have  found  Klebs-LofHer  bacillus 
either  in  pure  culture  or  with  other  pathogenic  bacteria.     Podak-Gerber 
reported  a  case  of  rhinitis  fibrinosa  with  true  bacillus  of  diphtheria  and 
streptococci  which  developed  an  acute  middle-ear  suppuration.     The 
culture  of  the  aural  secretion  showed  the  pseudodiphtheria  bacillus, 
numerous   streptococci,    and    staphylococci    aureus.     From    this   they 
drew  the  conclusion  that  pseudodiphtheria  bacilli  were  virulent  true 
diphtheria  bacilli.     Pseudodiphtheria  bacilli  are  related  morphologically 
and  in  culture  to  the  true  bacillus  of  diphtheria;  only  they  are  absolutely 
apathogenic.     Schilling  found  on  incising  an  acute  middle  ear  a  thick 
white  adherent  membrane  which  acted  bacteriologically  as  the  pseudo- 
diphtheria  bacillus;  it  was  not  pathogenic  for  guinea-pigs,  stained  by 
Gram's  method,  and  showed  Neisser's  granule  stain.     In  the  beginning 
of  the  disease  the  pseudobacillus  was  predominant,  but  later  it  was  killed 
out  by  diplococci.     It  was,  therefore,  a  mixed  infection  with  two  kinds  of 
bacteria.     A  fibrinous  exudate  in  the  middle  ear  should  not  be  diagnosed 
without  careful  bacteriologic  examinations. 

Influenza. — There  are  two  groups  of  influenza  otitis,  classified 
according  to  their  etiology:  First,  a  specific,  or  early  form,  caused  by 
the  influenza  bacillus,  wrhich  is  found  in  the  secretions  of  the  middle 
ear  gaining  entrance  by  the  blood-vessels.  This  form  usually  begins 


74  THE    PRINCIPLES    AND   PRACTICE    OF   OTOLOGY 

on  the  first  or  second  day  of  the  disease.  Second,  the  later  variety, 
a  secondary  infection  from  the  throat,  in  which  are  found  the  bacteria 
usually  present  in  acute  secondary  middle-ear  inflammation,  such  as 
diplococci,  staphylococci,  and  streptococci.  These  bacteria  have  also 
been  found  in  the  early  form,  but  they  have  been  overgrown  and  com- 
pletely supplanted  by  the  influenza  bacillus.  The  course  of  influenza 
otitis  varies  more  or  less  according  to  the  number  and  virulence  of  the 
bacilli  and  is  only  slightly  different  from  genuine  otitis.  A  special 
peculiarity  is  the  intensity  of  the  pain,  which  may  outlast  incision  of 
the  drum  membrane  or  spontaneous  rupture.  Some  epidemics  are 
characterized  by  a  hemorrhagic  form  of  otitis  media. 

Typhoid  Fever. — Two  to  four  per  cent,  of  all  cases  in  typhoid  fever 
have  ear  complications,  usually  in  the  fourth  to  the  fifth  week;  or,  accord- 
ing to  Bezold,  from  the  twenty-fifth  to  the  thirtieth  day.  The  typhoid 
bacillus  is  not  carried  by  the  blood;  clinically  the  middle-ear  inflamma- 
tion is  not  typical.  The  mastoid  process  is  often  involved.  Streptococci, 
staphylococci,  and  diplococci  are  found  in  the  aural  discharge  in  typhoid 
cases.  Preysing  found  the  typhoid  bacillus  in  a  case  with  double 
acute  purulent  otitis  media  in  which  the  drum  was  not  perforated.  In 
another  case  he  found  the  staphylococcus  albus  and  the  bacterium  coli. 

Cerebrospinal  Meningitis. — The  disease  of  the  middle  ear  is 
generally  secondary  to  the  disease  of  the  brain.  The  meningococcus 
intracellularis  (Weichselbaum-Jager)  progresses  from  the  brain  mem- 
branes to  the  inner  ear  along  the  auditory  nerve  or  frequently  through 
the  aqueductus  cochleae. 

Gonococcus. — The  gonococcus  is  rarely  found  in  the  middle  ear. 
The  writer  found  Neisser's  gonococcus  in  the  discharge  from  an  acute 
suppurative  otitis  in  an  infant  who  had  gonorrheal  ophthalmia.  The 
right  ear  only  was  affected. 

Otitis  Media.— The  following  bacteria  have  been  found  in  primary 
otitis  media: 

Streptococcus  pyogenes,  diplococcus  lanceolatus  (Frankel-Weichsel- 
baum),  staphylococcus  pyogenes  aureus  and  albus,  pneumobacillus 
(Friedlander),  bacillus  pyocyaneus,  bacterium  coli  commune,  influenza 
bacillus,  typhoid  bacillus,  streptococcus  erysipelatis,  bacterium  lactis 
aerogenes,  Neisser's  gonococcus,  bacillus  mucosus  ozaenae,  tubercle 
bacillus,  Klebs-Loffler  diphtheria  bacillus,  pest  bacillus,  meningococcus 
intracellularis  (Weichselbaum-Jager),  pseudodiphtheria  bacillus,  and 
bacillus  mucosus  capsulatus. 

Ferreri  mentions  a  specific  form  of  middle-ear  suppuration  in  cases 
of  rhinitis  atrophica  with  ozena  which  ran  a  long  course  and  did  not 


BACTERIOLOGY   OF    THE   EAR  75 

yield  to  treatment.  Cultures  in  2  cases  of  purulent  otitis  media  with 
ozena  showed  the  bacillus  mucosus  once  together  with  staphylococcus 
albus. 

Otitis  of  Infants. — Preysing  found  the  following  results  at  autopsy 
in  154  ear  cases  having  purulent,  mucous,  or  serous  contents  in  the 
middle  ears : 

Pneumococcus  (pure) 96  ears. 

Pneumococcus  with  putrefactive  bacilli 13  " 

Pneumococcus  and  staphylococcus 3  ' 

Streptococcus  (pure) i  " 

Staphylococcus  pyogenes  aureus 3  " 

Staphylococcus  and  putrefactive  bacilli 2  " 

Putrefactive  (pure) 3 

Sterile 33  " 

154      " 

Subtracting  these  33  sterile  cases,  Preysing  found  that  of  the  121 
remaining  infected  ears,  112  contained  pneumococcus,  or  about  92-^-  per 
cent,  of  all  bacteriologic  findings.  Preysing  says  that  this  fact  gives  us 
the  right  to  call  the  otitis  media  of  children  a  pneumococcic  infective 
disease. 

Complications  of  Middle-ear  Inflammation. — In  the  compli- 
cations of  middle-ear  inflammation,  such  as  mastoiditis,  meningitis, 
sinus  thrombosis,  epidural  abscess,  peri-auricular  abscess,  extra- 
dural  abscess,  and  brain  abscess,  the  same  bacteriologic  findings  are 
present,  found  in  the  middle  ear.  In  two-thirds  of  all  complications 
the  streptococcus  is  the  cause  and  in  one-third  the  staphylococcus  is 
the  cause.  This  is  the  inverse  relation  found  in  the  middle  ear.  Strep- 
tococci seem  to  melt  the  bone  away  and  is  the  most  common  cause  of 
sinus  thrombosis.  Gruening  found  pure  cultures  of  streptococci  in 
blood-cultures  taken  from  6  consecutive  cases  of  thrombosis  of  the 
lateral  sinus. 

"  The  formation  of  sinus  thrombosis  was  observed  by  Stenger,  who 
carried  on  inoculation  experiments  on  dogs.  He  injected  streptococci 
of  high  virulency  into  the  sigmoid  sinus  by  four  different  methods. 
A  tampon  covered  with  the  culture  was  laid  on  the  sinus  wall  or  carried 
along  the  sinus.  Again,  he  injected  the  streptococcus  into  the  sinus 
with  a  syringe  and  then  he  scratched  the  sinus  wall  and  laid  the  infected 
tampon  on  the  scratched  vessel.  Sinus  thrombosis  was  formed  only 
in  the  last  method.  Here  an  extensive  sinus  thrombosis  with  purulent 
destruction  of  the  thrombosis  took  place.  The  dog  died  of  general 
sepsis.  According  to  the  histologic  investigation  of  Koster  and  Talker 
there  was  a  gradual  disease  of  the  wall  of  the  vein  in  the  form  of  a 


76  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

lymphangitis.  The  blood  in  the  vein  coagulated  through  a  differentia- 
tion of  the  tissue  fluids  and  was  then  infected  by  bacteria;  therefore  the 
infection  by  bacteria  was  secondary."1 

According  to  Leutert,  epidural  abscesses  are  generally  caused  by 
diplococci.  In  brain  abscess  streptococcus,  staphylococcus,  and  diplo- 
coccus  have  been  found.  In  old  abscesses  of  the  brain  the  pus  may  be 
sterile.  In  many  cases  reported  sterile,  anaerobic  bacteria  were  not 
looked  for.  J.  Orne  Green  found  in  184  cases  of  mastoid  disease 
staphylococcus  in  pure  culture  49  times,  the  streptococcus  31  times, 
and  the  pneumococcus  23  times.  Green  came  to  the  conclusion  that 
the  variety  of  micro-organism  had  nothing  to  do  with  the  prognosis  of 
the  case.  Leutert  found  in  63  acute  ears  with  empyema  of  the  mastoid 
streptococci  in  pure  culture  38  times,  pneumococcus  in  pure  culture 
ii  times,  staphylococcus  in  pure  culture  5  times,  tubercle  bacillus 
in  pure  culture  twice,  and  the  remainder,  mixed  infections,  7  times. 

Staphylococcus  is  probably  the  most  frequent  cause  of  secondary 
infections  and  therefore  is  responsible  for  the  chronicity  of  aural  suppu- 
rations. In  chronic  otitis  media  the  pneumococcus  is  rarely  found, 
whereas  the  staphylococcus  is  always  found.  According  to  Coussieu, 
middle-ear  inflammation  with  several  bacterial  excitants  tend  to  become 
chronic,  whereas  the  presence  of  a  single  variety  of  bacteria  causes 
suppuration  of  short  duration  or  may  cause  no  suppuration  at  all. 
Acute  otitis  has  in  the  beginning  only  one  bacterial  excitant.  Staphylo- 
cocci  may  be  found  in  pure  culture,  but  they  are  not  so  frequently  the 
sole  excitors  as  diplococci  and  streptococci. 

Streptococcus  is  most  virulent,  but  soonest  loses  its  virulency;  the 
diplococcus,  according  to  Zaufal,  may  keep  up  its  virulency  to  the 
fifty-eighth  day  and,  rarely,  till  the  one  hundred  and  eighty-first  day. 

Gradenigo  found  that  diplococci  in  aural  pus  may  take  the  chain 
formation  and,  as  such,  represent  a  weakened  form  of  Frankel's  diplo- 
coccus. These  diplostreptococci  possess  all  the  peculiarities  of  the 
diplococcus  lanceolatus  capsulatus  in  an  attenuated  condition  and 
form  chains  on  agar.  The  capsule  is  lost.  They  belong  to  the  diplo- 
cocci and  not  to  the  streptococci.  These  diplococci  have  been  found 
by  Marie  Raskin,  Moos,  Hasslauer,  and  others.  Probably  these  bacteria 
have  been  classed  as  streptococci  by  many  observers,  which  may  account 
for  the  diversity  of  results. 

The  pneumococcus  differs  from  the  streptococcus  in  three  ways : 

(i)  The  acute  process  runs  a  quicker  course  in  the  middle  ear  in 
pneumococcus  infection. 

1Stenger,  "Transactions  of  the  German  Otological  Society  in  Berlin,  1904,"  p.  109. 


BACTERIOLOGY   OF   THE    EAR  77 

(2)  The  pneumococcus  has  a  greater  inclination  to  extend  its  field 
of  infection  than  streptococcus.     (Epidural  abscesses  are  more  frequent.) 

(3)  Pneumococcus  infection  often  remains  latent  a  long  time  in  the 
middle  ear  after  its  acute  course,  before  it  starts  up  an  acute  process 
in  the  mastoid. 

Netter  classified  middle-ear  inflammations  clinically  according  to 
the  bacteria  and  the  nature  of  the  discharge,  but  it  is  known  that  the 
intensity  of  an  inflammation  depends  not  only  on  the  kind  and  virulence 
of  the  micro-organism,  but  also  on  the  resistance  of  the  tissues  of  the 
individual.  The  same  micro-organism  which  causes  a  catarrhal  inflam- 
mation may  generate  a  suppurative  inflammation  depending  on  the 
virulence  of  the  germ,  its  numbers,  and  the  method  of  spreading;  for 
example,  its  method  of  spreading  in  the  middle  ear  depends  on  the 
resistant  powers  of  the  organism  and  the  anatomic  character  of  the  tissues. 
It  is  established  that  certain  bacteria,  after  remaining  some  time  in  the 
nasopharynx,  become  attenuated;  and  the  same  process  takes  place 
in  the  middle  ear. 

CONCLUSIONS 

A  pneumococcic  suppuration  is  in  general  more  favorable  in  its 
course  than  a  streptococcic  suppuration.  A  monobacterial  infection 
is  more  favorable  than  a  polybacterial  infection.  Although  a  pneumo- 
coccic infection  seems  to  get  well  sooner,  it  may  be  latent  and  the 
inflammation  may  start  up  again  in  the  mastoid  process  or  meninges 
after  apparent  healing  has  taken  place. 

The  same  bacteria  are  found  in  empyema  of  the  mastoid  that  are 
found  in  acute  middle-ear  inflammation. 

Careful  technic  is  essential  to  success.  A  smear  should  always  be 
taken,  because  some  of  the  bacteria  may  not  grow  on  the  culture-media. 
A  culture  should  be  grown  and  an  inoculation  should  be  made  in  all 
cases  of  suspected  diphtheria  or  tuberculosis. 

Blood-cultures  are  important  in  cases  of  suspected  sinus  thrombosis. 
Sinus  thrombosis  most  frequently  accompanies  streptococcic  infection. 
An  otitis  caused  by  a  single  bacterium  is  generally  followed  by  no  suppu- 
ration or  a  suppuration  lasting  but  a  short  time.  If  one  finds  in  the 
beginning  of  a  middle-ear  suppuration  several  infective  bacterial  ex- 
citors,  pathogenic  alone  or  pathogenic  mixed  with  saprophytes,  then 
the  otitis  inclines  to  chronicity. 

Bacteria  play  an  important  role,  but  do  not  help  always  in  making  a 
prognosis  or  in  warning  us  of  brain  complications.  We  should  be 
careful  not  to  introduce  new  and  perhaps  more  virulent  bacteria,  and 


78  THE   PRINCIPLES  AND   PRACTICE   OF  OTOLOGY 

for  this  reason  the  most  careful  asepsis  should  be  carried  out.  Strong 
antiseptic  solutions  should  not  be  used,  but  such  sterile  solutions  which 
cause  the  least  irritation — e.  g.,  normal  salt  solution.  Only  sterilized 
sticks  of  absorbent  cotton  introduced  into  the  auditory  canal  with 
forceps  or  cotton  wound  on  cotton  sticks  and  held  in  the  flame  should 
be  used  in  cleansing  the  auditory  canal.1 

These  conclusions  are  interesting  from  a  scientific  point  of  view; 
practically,  the  bacteriology  of  the  ear  is  one  of  the  least  important  aids 
in  diagnosis  of  aural  diseases  and  their  complications. 

1  B.  Goniperz,  "Zur  Sterilisierung  der  Tupfer  Pinsel  und  Einlagen  fur  Ohr  und  Nase." 
Zeit.  f.  Ohrenheilkunde,  LI.,  Band,  Ersten  Heft. 


CHAPTER  IV 
THE  CAUSATION  OF  EAR  DISEASES 

IT  is  not  the  intention  to  discuss  here  the  causes  of  aural  ailments 
except  in  that  broad  and  general  way  which  is  necessary  to  give  an 
intelligent  understanding  of  the  subject  as  a  whole;  because  in  dealing 
with  each  separate  disease  in  the  subsequent  chapters  of  the  work  the 
question  of  causation  will  again  be  dealt  with  more  specifically. 

When  collectively  considered  in  respect  to  their  etiology  it  may  be 
said  that  aural  affections  arise  from  injurious  agents  acting  from  without 
through  the  external  auditory  meatus;  from  the  nasopharynx  through 
the  Eustachian  tube,  and  finally,  from  systemic  diseases  which,  during 
their  progress,  and  acting,  no  doubt,  through  the  medium  of  the  blood 
and  lymph,  involve  some  portion  of  the  hearing  apparatus. 

As  to  the  relative  frequency  with  which  each  of  the  above  influences 
brings  about  the  aural  affection,  the  causes  that  act  through  the  naso- 
pharynx by  way  of  the  Eustachian  tube  stand  first,  those  acting  through 
the  external  auditory  meatus  second,  and  those  produced  secondarily 
by  general  ailments  of  the  system  last. 

Chief  among  the  agents  that  cause  aural  disease  by  entering  the 
auditory  meatus  may  be  mentioned: 

Loud  Noises. — The  explosion  of  a  gun  or  a  blast  of  any  kind  when 
occurring  near  the  ear  may,  by  the  sudden  impact  of  air  against  the 
tympanic  membrane,  be  sufficient  to  injure  and  sometimes  to  rupture 
this  structure.  It  is  believed  that  an  explosion  of  moderate  intensity 
will  never  cause  a  rupture  unless  there  has  been  a  previous  weakening 
of  the  tympanic  membrane  due  to  a  former  disease  of  this  structure 
which  resulted  in  an  atrophy  of  the  part.  Middle-ear  injuries  resulting 
to  men  who  are  constantly  engaged  in  work  like  blasting  are  frequently 
complicated  by  labyrinthine  deafness.  The  ear  is  injured  in  a  somewhat 
similar  manner  to  that  which  results  from  explosions  by  the  rarefaction 
and  condensation  of  the  air  which  takes  place  in  the  auditory  canal 
of  those  who  work  in  caissons  or  of  those  who  ascend  to  great  heights 
in  balloons.  Under  such  atmospheric  conditions  the  condensation  and 
rarefaction  of  the  air  takes  place  less  suddenly  than  during  an  explosion, 
and  there  is  consequently  not  sufficient  violence  to  the  drum  membrane 
to  produce  a  rupture;  but  the  disturbance  to  the  circulation  of  the 

79 


80  THE   PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 

middle  ear  which  takes  place  under  these  circumstances  is  productive 
of  serous  transudations,  or  even  hemorrhage  into  the  tympanic  cavity, 
which  may  sooner  or  later  result  in  either  tympanic  or  labyrinthine 
deafness. 

Cold  and  Heat. — The  entrance  of  cold  water  into  the  meatus  may 
cause  an  inflammation  of  the  drum-head  or  even  a  suppurative  inflamma- 
tion of  the  middle  ear.  This  is  particularly  true  if  the  water  enters  the 
canal  with  force,  as  from  a  wave  striking  the  ear  while  surf-bathing  or 
from  an  individual  striking  the  water  with  the  side  of  the  head  in  high 
diving.  Prolonged  exposure  of  the  ear  to  a  cold,  damp  wind  may 
produce  the  same  result.  Molten  metal  and  boiling  water  or  steam, 
when  entering  the  ear  accidentally,  set  up  a  most  violent  inflammation, 
and  the  deep  necrosis  which  follows  may  prove  not  only  destructive  to 
function  but  also  to  life. 

Foreign  bodies,  if  large  or  rough  or  if  hurled  into  the  ear  with  force, 
produce  not  only  contusion  and  laceration  of  the  auditory  canal,  but 
may  also  cause  rupture  of  the  tympanic  membrane  with  subsequent 
destruction  of  the  conducting  portion  of  the  middle  ear.  Awkward 
and  unskilful  efforts  on  the  part  of  the  physician  to  remove  smaller 
and  therefore  harmless  foreign  bodies  from  the  auditory  meatus  may 
result  in  serious,  though  entirely  unwarranted,  injury  to  the  hearing 
apparatus. 

Injuries  jrom  jails  or  blows  are  among  the  causes  of  middle-ear  or 
labyrinthine  affections.  The  attachment  of  the  posterosuperior  integu- 
mentary lining  of  the  auditory  meatus  to  the  adjacent  portion  of  the 
drum  membrane  is  such  that  a  rupture  of  the  latter  structure  may  occur 
as  the  result  of  suddenly  and  vigorously  pulling  the  auricle  upward 
and  backward,  as  is  sometimes  practised  as  a  method  of  punishment. 
A  box  on  the  ear,  causing  condensation  of  the  air  in  the  auditory  canal, 
may  rupture  the  membrana  tympani.  Falls  upon  the  head  may  fracture 
the  ossicles  and  rupture  the  membrane  (see  Figs.  133,  134),  either 
with  or  without  a  fracture  of  the  base  of  the  skull  (see  Fig.  305). 

General  Diseases  as  Causative  Agents. — Among  the  chronic 
diseases  that  cause  aural  affections  secondarily,  those  of  a  strumous, 
tubercular,  or  luetic  nature  stand  first.  Aural  discharges  of  tubercular 
origin  are  probably  more  frequent  than  has  heretofore  been  realized, 
although  a  bacteriologic  examination  of  the  pus  in  most  cases  of  suppura- 
tive otitis  media  fails  to  show  the  presence  of  the  tubercle  bacillus.  In 
children  especially  the  tubercular  aural  affection  is  seen  in  connection 
with  enlarged  and  sometimes  suppurating  cervical  glands,  in  ^-hich 
instances  mastoiditis,  with  extensive  necrosis  of  the  mastoid,  is  not 


THE    CAUSATION   OF    EAR   DISEASES  8l 

infrequent.  Syphilis  may  produce  an  acute  tubal  or  tubotympanic 
catarrh  during  the  inflammatory  manifestations  that  take  place  in  the 
nose  and  throat  in  the  secondary  stage.  This  tubal  affection  may 
become  chronic  if  the  luetic  disease  progresses  to  the  tertiary  stage, 
when  it  may  then  affect  not  only  the  middle  ear  but  also  the  labyrinth, 
in  which  case  the  final  outcome  will  most  probably  be  a  greatly  im- 
paired hearing  or  even  total  deafness  in  one  or  both  ears.  Effusion  of 
serum  or  even  blood  sometimes  takes  place  into  the  labyrinth  during 
the  course  of  syphilis,  and  in  addition  to  the  sudden  and  profound 
deafness  thus  produced  severe  tinnitis  aurium  or  vertigo  and  vomiting 
may  occur.  These  aggravated  results  of  syphilis  may  be  accompanied 
by  active  general  manifestations  of  the  disease  upon  the  skin  and  mucous 
membranes  or,  the  patient  having  long  since  thought  himself  cured,  the 
physician  may  only  be  able  to  connect  the  remote  cause  and  the  effect 
upon  the  ear  by  means  of  the  discovery  of  old  cicatrices  in  the  throat, 
by  a  perforated  palate  or  nasal  septum,  or  perhaps  by  the  presence  of 
scars  upon  the  cornea.  Several  acute  diseases  are  frequently  accom- 
panied or  followed  by  an  aural  affection,  which  seems  to  be  the  result 
of  a  toxic  disturbance  to  the  nerve  or  circulatory  supply  of  the  labyrinth. 
Among  this  class  of  general  diseases,  typhoid  and*  typhus  fevers  and 
mumps  are  especially  notable. 

The  exanthemata  are  by  far  the  most  frequent  of  all  the  general 
diseases  in  the  production  of  the  pathogenic  bacteria  which  are  essential 
to  the  development  of  the  suppurative  aural  affections.  The  harmful 
action  upon  the  hearing  organ  that  results  from  these  general  diseases 
may  take  place  through  the  circulatory  disturbances  that  occur  in  the 
middle  ear  and  labyrinth  during  the  progress  of  the  general  affection; 
chiefly  through  the  accompanying  inflammation  of  the  upper  respiratory 
tract  and  particularly  of  the  nasopharynx  This  inflammation  often 
rapidly  extends  to  the  middle  ear,  and  when  infection  of  the  latter  takes 
place  is  thus  primarily  responsible  for  the  many  violent  and  destructive 
processes  that  occur  in  this  and  the  adjoining  cavities.  The  author, 
therefore,  believes  that  these  general  diseases,  when  considered  in  their 
causative  relation  to  the  diseases  of  the  ear,  can  be  more  properly  con- 
sidered under  the  following  division: 

Causes  that  Act  through  the  Nasopharynx  and  Eustachian 
Tube. — The  marked  influence  which  congestion,  inflammation,  or 
obstructive  growths  in  the  nose  and  nasopharynx  has  upon  the  produc- 
tion of  diseases  in  the  middle  ear  and  mastoid  is  recognized  by  all 
observers.  Congestion  or  inflammation  in  the  tympanic  cavity  may 
occur  through  extension  of  these  disturbances  from  the  throat  to  the  ear 

6 


82  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

by  continuity  of  structure,  or  because  a  disturbed  circulation  in  the 
throat  may,  through  vascular  communication,  produce  stagnation, 
exudation,  and  subsequent  infection  of  the  cavities  of  the  middle  ear. 
Growths  either  in  the  nose  or  nasopharynx  may  sometimes  act  mechan- 
ically to  obstruct  the  passage  of  air  into  the  tympanum;  their  pressure 
upon  adjacent  structures  also  retards  the  venous  circulation  from  both 
nasopharynx  and  middle  ear,  causing  passive  congestion  and  exudation 
into  the  tympanum ;  finally,  the  obstruction  they  offer  to  the  free  drainage 
of  the  tympanum  and  its  environs  favors  the  growth  of  numerous  bac- 
teria which  are  ever  ready  to  migrate  from  the  throat  to  the  ear,  where 
their  presence  upon  an  already  weakened  membrane  may  be  sufficient 
to  set  up  the  most  violent  and  destructive  inflammatory  processes. 

In  the  above  ways,  therefore,  the  presence  of  nasopharyngeal  adenoids 
becomes  a  constant  menace  to  the  integrity  of  the  organ  of  hearing. 
The  deep  fissures  that  penetrate  or  separate  the  lobes  of  these  growths 
are  constantly  bathed  with  a  thick  secretion  which  is  difficult  to  dislodge 
and  which  furnishes  the  pabulum  for  the  growth  of  pathogenic  bacteria. 
When  nasal  or  nasopharyngeal  tumors  are  large  enough  to  block  the 
postnasal  spaces  and  thus  prevent  the  passage  of  air  through  the  nostrils 
every  act  of  swallowing  rarefies  the  air  within  the  nasopharyngeal  space 
and  likewise  that  within  the  middle  ear,  the  defective  ventilation  re- 
sulting in  impairment  of  hearing,  tinnitis  aurium,  middle-ear  exudation, 
perforation,  and,  finally,  aural  discharge  with  all  the  subsequent  pos- 
sibilities of  mastoid  and  intracranial  complication. 

The  question  as  to  whether  or  not  the  presence  of  disease  germs 
in  the  middle  ear  will  cause  inflammation  in  the  absence  of  any  pre- 
existing congestion  or  inflammation  of  that  cavity  seems  not  to  be  defi- 
nitely settled.  It  is  stated  by  some  that  in  the  event  of  pathogenic  germs 
finding  their  way  into  the  healthy  tympanic  cavity,  they  ultimately 
perish  without  having  caused  any  local  disturbance.  However  this 
may  be,  all  observers  are  agreed  upon  the  fact  that  in  the  presence  of  a 
congestion  or  inflammation  within  the  tympanum,  with  perhaps  resulting 
exudate,  the  addition  of  certain  bacteria  are  the  prime  factors  in  the 
subsequent  suppuration  and  destruction  of  tissue.  If  we  add  to  the 
list  of  the  causative  relations  already  attributed  to  adenoids  and  other 
growths  in  the  production  of  aural  disease  the  additional  ones  that  the 
patient  usually  sleeps  badly,  is  often  poorly  oxygenated,  and  frequently 
suffers  from  stomach  and  intestinal  derangements,  it  may  be  better 
understood  how  much  more  easily  the  preceding  causes  may  become 
effective. 

Acting  in  a  systemic  manner  certain  drugs  produce  disturbances  of 


THE    CAUSATION   OF   EAR   DISEASES  83 

audition,  and  if  their  use  be  continued  for  a  great  length  of  time  perma- 
nent effects  on  the  function  may  result.  A  list  of  the  more  active  medi- 
cines of  this  class  includes  alcoholics,  salicylates,  opium,  and  especially 
quinin,  which  latter,  when  given  in  large  doses,  as  is  the  custom  in 
malarial  districts,  produces  marked  and  permanent  effects  on  the 
hearing  power. 

In  addition  to  the  above  division  of  causes,  certain  others,  which 
do  not  come  under  any  one  of  the  classes,  are  nevertheless  sometimes 
present.  Among  these  are  age,  predisposition,  and  environment. 
Each  period  of  life  seems  to  bear  some  relation  to  the  frequency  with 
which  certain  aural  ailments  are  met.  Thus  in  childhood  the  catarrhal 
and  suppurative  diseases  are  commonest.  This  fact  is  accounted  for 
largely  because  the  exanthematous  diseases  are  most  common  in  early 
life,  because  of  the  greater  frequency  of  adenoids  at  this  age,  and  because 
of  the  anatomic  differences  in  the  structure  of  the  nasopharynx  and 
Eustachian  tube.  Adhesive  and  dry  forms  of  middle-ear  inflammation 
which  are  often  accompanied  by  labyrinthine  complications  are  most 
often  seen  in  adults  and  those  advanced  in  years.  In  old  age  the  walls 
of  the  external  auditory  meatus  and  also  of  the  mucous  membrane  of 
the  Eustachian  tube  sometimes  become  flaccid,  collapse,  and  occlude 
the  respective  channels  to  the  extent  of  seriously  interfering  with  their 
proper  functions. 

Predisposition  or  heredity  has  an  undoubted  influence  in  the  produc- 
tion of  some  cases  of  adhesive  aural  catarrh,  and  families  are  not  infre- 
quent in  whom  several  members  are  similarly  affected,  the  disease 
beginning  at  about  the  same  age  in  each  and  continuing  to  old  age. 
A  peculiarity  of  heredity  as  a  causative  factor  in  diseases  of  the  ear 
is  noted  in  the  fact  that  the  children  of  parents  afflicted  by  this  type  of 
aural  disease  may  escape  with  good  hearing,  whereas  the  succeeding 
generation  is  likely  to  develop  the  ailment  in  the  original  form  and  at 
the  corresponding  age  at  which  the  grandparents  became  affected. 

Mode  of  life  and  social  position  are  factors  in  the  causation  of  many 
forms  of  ear  disease.  Children  who  are  badly  nourished  and  who 
are  poorly  clothed  and  filthily  housed  suffer  most  frequently  from 
skin  affections  of  the  auricle  and  external  auditory  meatus;  and  a  life 
spent  under  these  latter  conditions  also  predisposes  to  suppurative 
disease  at  all  periods. 


CHAPTER  V 
DISEASES   OF   THE   EXTERNAL   EAR 

DISEASES  of  the  auricle  may  be  congenital  or  acquired.  Among  the 
congenital  affections  the  most  important  are  the  various  defects  or 
abnormalities  of  the  several  portions  of  the  auricle — entire  absence  of 
the  auricle,  excessive  size  of  one  or  both  pinnae,  irregular  shape  of 
outline  together  with  thinning  of  the  cartilage  which  comprises  the 
auricle,  and  more  or  less  obliteration  of  the  folds  which  constitute  the 
helix  and  antihelix.  The  conditions  known  as  polyotia  and  microtia 
are  also  congenital.  Chief  among  the  acquired  affections  are  the 
various  skin  eruptions  and  tumors  which  occur  upon  the  outer  ear, 
and  also  the  deformities  of  the  auricle  which  are  the  result  of  injuries 
to  this  portion  of  the  hearing  organ. 

Since  the  auricle  in  man  plays  but  a  small  part  in  the  production  of 
hearing,  its  diseases  and  deformities  do  not,  as  a  rule,  produce  any 
degree  of  deafness  except,  when  through  lack  of  development,  there 
is  a  coexisting  absence  or  incompleteness  of  the  conducting  or  perceptive 
portions  of  the  ear,  or  unless  the  swelling,  growth,  or  deformity  of  the 
pinna  is  of  such  nature  as  to  block  the  auditory  meatus  and  prevent  the 
entrance  of  the  sound-waves.  The  treatment  of  this  class  of  diseases 
is,  therefore,  necessary  only  on  account  of  the  unsightly  appearance 
produced  by  the  auricular  deformity  or  disease,  or  for  the  purpose  of 
relieving  pain  and  itching  or  possibly  to  arrest  the  progress  of  some 
malignant  growth  and  not  for  the  improvement  of  impaired  function. 

MALFORMATION   OF   THE   AURICLE 

Undeveloped  Helix. — The  helix  is  sometimes  ill  developed  and 
does  not  turn  forward  and  downward  into  its  normal  scroll.  In  many 
such  instances  the  whole  pinna  is  abnormally  large,  while  the  cartilagin- 
ous framework  is  unusually  thin;  the  whole,  especially  if  pointed  at  the 
upper  extremity  so  as  to  form  the  so-called  satyr  ear,  much  resembling 
that  of  an  animal  (Fig.  58).  On  the  contrary,  the  helix  may  be  thick 
and  the  upper  portion  of  the  auricle  may  be  turned  downward  and 
forward  to  an  unusual  extent;  the  helix  may  even  be  adherent  to  the 
anterior  surface  of  the  pinna.  When  these  conditions  are  found  the  ear 

84 


DISEASES    OF   THE    EXTERNAL    EAR 


is  usually  small  and  the  cartilage  abnormally  thick,  the  whole  condition 
comprising  that  known  as  "lop  ears"  (Fig.  59). 

Absence  of  Lobule. — The  lobule  may  be  absent  (see  Fig.  62)  or  may 
be  greatly  hypertrophied.  The  latter  condition  is  most  common  among 
the  negro  races,  in  some  of  whom  the 
lobe  is  enormous  in  size.  This  portion 
of  the  auricle  is  sometimes  enlongated  in 
those  women,  chiefly  of  foreign  birth,  who 
wear  large  and  heavy  earrings.  Occa- 
sionally the  earring  cuts  its  way  through 
the  lobe  or  it  may  be  suddenly  pulled 
through  it,  and  in  either  case  a  divided 
lobule  is  the  result. 

Cartilaginous  projections  from  the 
tragus  or  near  it  are  sometimes  congeni- 
tally  present  (Fig.  60) .  These  are  com- 
monly about  ^  inch  wide  at  the  base  and 
from  f  to  i  inch  in  length,  gradually  taper- 
ing from  the  base  to  a  blunt  point  in  an 
upward,  forward,  or  downward  direction. 

Treatment. — The    large,    thin,   ill-shaped    "  animal    ear  "    usually 
occurs  in  individuals  who  care   little  concerning  the  deformity,  and 


FIG.  58. — DEFORMED  AND  POINTED  HELIX 
OF  AN  INSANE  INDIVIDUAL.     Satyr  ear. 


FIG.  sg. — LOP  EARS,  RIGHT  AND  LEFT,  OF  SAME  PERSON. 

since  no  pain  or  other   inconvenience  accompanies  the  deformity  the 
surgeon  is  not  often  consulted  concerning  it. 

In  the  case  of  lop  ears  a  correction  is  more  often  sought,  and  may 
be  secured  by  a  plastic  operation  in  which  a  section  of  the  skin  covering 


86 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


the  posterior  surface  of  the  auricle  and  including  the  underlying  car- 
tilage is  included.  The  technic  of  the  operation  consists  in  the  usual 
aseptic  preparation  of  the  field  of  operation,  hands,  and  instruments, 
and  the  administration  of  an  anesthetic.  An  incision  is  made  on  the 
posterior  surface  of  the  pinna,  beginning  near  the  furrow  marking  the 
superior  attachment  of  the  auricle  to  the  head,  and  continuing  downward 
parallel  to  the  border  of  the  ear,  and  at  a  distance  from  the  border 
which  varies  according  to  the  amount  of  "  lopping  "  which  is  to  be  cor- 
rected. The  length  of  this  incision  is  governed  entirely  by  the  extent 
of  the  anterior  folding  of  the  cartilage.  Likewise  the  width  of  the 
elliptic  piece  of  skin  and  cartilage  which  is  to  be  removed  is  governed 


FIG.  60. — CARTILAGINOUS  PROJECTION  FROM  THE  FIG.  61. — LINES  OF  INCISION  FOR  REDUCING  AB- 

TRAGUS.  NORMALLY  LARGE  AURICLE. 

Lines  a,  b,  c  indicate  incisions  for  reducing  the 
vertical  diameter ;  lines  d,  e  and  /,  g  the  incisions 
necessary  to  narrow  the  transverse  diameter. 

by  the  extent  of  the  deformity  to  be  overcome.  When  the  elliptic 
piece  of  cartilage  is  dissected  from  the  skin  which  covers  the  correspond- 
ing portion  of  the  anterior  surface  of  the  ear  care  must  be  exercised  not 
to  injure  it  in  any  manner,  since  if  this  part  of  the  auricular  integument 
be  injured  more  or  less  visible  scar  will  result.  Three  or  more  inter- 
rupted catgut  sutures,  which  should  be  passed  through  the  cartilage, 
are  subsequently  employed  for  bringing  the  edges  of  the  wound  to- 
gether, after  which  collodion  is  applied  to  the  line  of  union,  a  pad  of 
gauze  is  placed  behind  the  ear,  and  a  roller  bandage  is  applied  to  hold 
the  auricle  in  a  fixed  position  until  healing  occurs.  If  judgment  has  been 
used  as  to  the  size  of  the  piece  of  skin  and  cartilage  which  has  been 
removed,  and  if  skill  and  cleanliness  were  employed  in  the  execution 


DISEASES   OF   THE   EXTERNAL   EAR  87 

of  the  same,  a  very  gratifying  result  may  be  obtained  by  the  above 
method. 

Cartilaginous  spurs  (Fig.  60)  which  spring  from  the  vicinity  of  the 
tragus  may  be  easily  removed  by  forming  an  outer  skin  flap,  which  is 
dissected  down  to  the  base  of  the  growth,  which  latter  is  at  this  point 
excised,  and  lastly  by  stitching  the  flap  over  the  stump,  using  fine  cat- 
gut sutures.  Practically  no  scar  is  left  when  the  spur  is  carefully 
removed  by  this  method.  A  greatly  enlarged  lobule  could  be  easily 
removed  by  plastic  methods,  but  the  surgeon  is  seldom  requested  to 
perform  this  operation. 

In  case  the  auricle  is  larger  than  its  fellow  and  protrudes  from  the 
side  of  the  head  in  an  unsightly  manner,  both  the  redundant  size  and 
abnormal  position  may  be  satisfactorily  corrected  by  a  plastic  operation. 
To  successfully  reduce  both  the  vertical  and  horizontal  diameters  of 
the  ear,  triangular  pieces  including  the  entire  thickness  of  the  ear  are 
removed  (Fig.  61),  after  which  remaining  parts  of  the  auricle  are 
accurately  adjusted  and  held  in  place  by  interrupted  sutures.  The 
completed  dressing  is  made  after  the  manner  designated  in  the  operation 
for  lop  ears.  When  this  operation  is  performed  on  an  individual  in 
whom  the  opposite  ear  is  normal  both  in  size  and  position,  a  satisfactory 
outcome,  in  so  far  as  the  esthetic  effect  is  concerned,  will  depend  very 
much  on  the  accuracy  in  judgment  which  is  exercised  by  the  surgeon 
as  to  the  size  of  the  wedge-shaped  pieces  which  are  removed;  for  if 
these  be  too  large  it  is  obvious  that  the  resulting  auricle  will  be  too  small, 
whereas  if  the  wedges  are  not  large  enough,  the  operation  will  not 
completely  correct  the  deformity.  An  error  in  either  direction  will 
result  in  disappointment. 

Microtia  and  Entire  Absence  of  the  Auricle. — Microtia,  as  its 
name  indicates,  is  a  congenital  defect  of  the  auricle  in  which  the  ear  is 
without  definite  form,  often  amounting  to  nothing  more  than  a  tab  of  skin 
at  or  in  the  vicinity  of  the  site  of  the  normal  ear  (Fig.  62).  Sometimes 
this  fold  of  skin  contains  cartilage,  and  the  whole  may  be  compressed 
and  adherent  to  the  side  of  the  head,  the  same  covering  the  site  of  the 
external  auditory  meatus.  This  class  of  auricular  malformation  is 
usually  associated  with  a  lack  of  development  of  other  portions  of  the 
auditory  apparatus.  Thus,  in  a  case  of  microtia,  the  external  auditory 
canal  may  be  entirely  wanting  or  a  depression  only  may  mark  its  normal 
situation.  In  patients  who  are  old  enough  to  give  reliable  information 
as  a  result  of  tuning-fork  tests  it  is  frequently  ascertained  that  bone 
conduction  is  deficient  or  absent,  which  fact  would  indicate  a  lack  or 
even  a  complete  failure  of  development  of  the  internal  ear.  This 


88  THE   PRINCIPLES   AND  PRACTICE   OF   OTOLOGY 

defect  may  include  one  or  both  ears.  It  is  often  associated  with  defec- 
tive mental  development  and  with  malformation  of  the  face  and  mouth. 

Treatment. — Correction  of  this  class  of  malformation  is  usually 
impossible.  The  position  and  shape  of  the  skin-tabs  representing  the 
auricle  are  often  such  that  the  individual's  appearance  is  improved  by 
their  complete  removal,  in  which  case  the  attempt  may  be  made  to 
substitute  an  artificial  pinna. 

Various  operative  measures  have  been  suggested  for  improving 
the  hearing  in  this  class  of  cases,  but  none  have  ever  succeeded  in  doing 
so  with  any  considerable  degree  of  satisfaction.  In  case  the  patient 
is  old  enough  to  give  reliable  information  concerning  the  functional 
examination,  and  it  is  positively  ascertained  that  the  impaired  hearing 


FIG.  62. — MICROTIA.     (Dench.) 

is  due  to  a  defect  in  the  conducting  portion  of  the  ear,  operative  measures 
should  always  be  advised  in  the  hope  that  it  is  possible  to  restore  the 
auditory  meatus  and  thus  admit  sound-waves  to  the  perceptive  portion 
of  the  ear.  The  first  step  of  this  operation  is  performed  by  removing 
all  tabs  of  skin,  then  making  a  crucial  incision  over  the  presumed  site 
of  the  external  auditory  meatus,  and,  finally,  lifting  each  of  the  four 
flaps  from  the  bone  by  means  of  a  periosteal  elevator  (see  Fig.  161).  The 
exposed  skull  surface  should  always  be  of  sufficient  extent  to  enable 
the  operator  to  see  clearly  any  landmark  upon  the  temporal  bone  that 
may  be  present,  and  to  discover  any  opening  which  may  lead  into  the 
cavium  tympani.  If  no  such  opening  is  present  the  operation  should 
be  abandoned  for  the  reason  that  in  operating  without  any  such  guide 


DISEASES    OF    THE    EXTERNAL    EAR 


injury  may  be  done  to  the  brain,  lateral  sinus,  or  facial  nerve.  Should, 
however,  a  fistulous  tract  be  found  leading  to  the  middle  ear,  the  same 
should  be  enlarged  by  means  of  small  gouges,  which  are  used  in  the 
manner  advocated  in  doing  the  radical  mastoid  operation  (see  p.  385). 
When  the  operation  is  undertaken  the  same  anatomic  knowledge  should 
be  available,  and  the  same  care  and  skill  should  be  exercised  as  when 
performing  the  radical  mastoid  operation.  After  the  intervening  osseous 
tissues  have  been  removed,  and  the  newly  constructed  auditory  meatus 
has  been  honed  perfectly  smooth  by  means  of  the  curet  or  dental  burr, 
the  triangular  skin  flaps  are  tucked  into  the  newly  formed  meatus  and 
are  held  snugly  against  the  osseous  walls  by  means  of  a  light  gauze  pack- 
ing until  adhesion  takes  place.  Much  of  the  raw  surface  is  in  this 
way  lined  with  skin,  from  which  the  epithelium  will  soon  grow  and 
cover  the  remaining  denuded  areas. 

Supernumerary  Auricles.  Polyotia. — Instances  of  the  presence  of 
more  than  one  ear  on  each  side  of  the  head  have  been  recorded  (Fig.  63). 
Wilde  saw  a  case  having  four  auricles, 
two  in  the  natural  position,  while  the  ad- 
ditional two  were  located  on  the  neck.  In 
this  case  it  was  stated  that  there  were  also 
two  petrous  portions  for  each  temporal 
bone.  The  supernumerary  auricle  may 
be  unilateral  or  bilateral;  it  may  be  more 
or  less  perfectly  formed  or  may  be  nothing 
more  than  a  tab  of  skin,  as  in  the  case 
reported  by  Birkett,  in  which  a  young  girl 
had  a  large  growth  resembling  a  lobule 
which  sprang  from  the  middle  of  the  neck 
over  the  sternomastoid  muscle.  The  mass 
contained  fibrocartilage.  Multiple  auricles  are  always  found  over  the 
lines  of  the  branchial  clefts  and,  according  to  Paget,  may  be  considered 
as  cutaneous  growths,  which  though  abnormal  are  homologous  with 
the  natural  auricles. 

Treatment. — The  supernumerary  auricles  may  be  removed  surgically. 
A  flap  of  skin  sufficiently  large  to  cover  the  base  of  the  auricle  after  the 
excision  is  performed  is  first  dissected  from  the  appendage,  and  this 
flap  is  then  stitched  into  place  by  the  requisite  number  of  fine  catgut 
sutures.  If  the  auricle  which  is  located  in  the  normal  situation  is 
malformed,  attempts  may  be  made  to  correct  the  malformation  by  the 
plastic  method  already  described.  If  the  external  auditory  meatus 
is  closed  and  the  functional  examination  proves  that  the  perceptive 


FIG.  63. — POLYOTIA. 


QO  THE   PRINCIPLES   AND    PRACTICE    OF   OTOLOGY 

apparatus  is  not  involved,  the  same  operation  which  was  advised  under 
microtia  for  the  establishment  of  a  tympanic  communication  may  be 
undertaken  (see  p.  88). 

Congenital  Fistulas. — These  are  usually  found  just  in  front  of  the 
tragus  or  upon  the  face  immediately  in  front  of  the  attachment  of  the 
helix.  The  orifice  leading  into  the  fistulous  tract  is  often  so  insignificant 
as  to  admit  only  the  smallest  probe  and  the  depth  of  the  fistula  is  usually 
not  greater  than  5  or  6  mm.  The  channel  represents  the  position  of  the 
second  branchial  cleft  and  is  not  in  any  way  connected  with  the  middle 
ear.  Its  presence  may  be  entirely  overlooked  except  upon  the  most 
careful  inspection,  for  the  mouth  is  often  hidden  by  a  fold  in  the  adjacent 
skin.  Such  fistulae  give  rise  to  no  inconvenience  whatever  unless,  as 
sometimes  happens,  there  is  an  accumulation  of  cystic  material  or 
unless  some  foreign  body  has  entered  the  channel.  In  either  case  an 
inflammatory  swelling  may  result.  No  treatment  is  usually  necessary. 
Should  a  cyst  formation  take  place  the  fistula  should  be  laid  open  and 
its  path  be  cureted  or  cauterized,  after  which  the  parts  are  held  in  contact 
by  a  compress,  when  complete  obliteration  of  the  cleft  promptly  occurs. 


CHAPTER  VI 
DISEASES  OF  THE  AURICULAR  PERICHONDRIUM 

PERICHONDRITIS 

INFLAMMATION  of  the  perichondrium  may  result  from  an  injury  to  the 
auricle,  may  be  due  to  the  outward  extension  of  an  infection  of  the  audi- 
tory canal,  or  may  develop  without  any  known  cause.  Numerous  cases 
have  been  reported  in  which  a  perichondritis  has  occurred  subsequently 
to  the  radical  mastoid  operation,  during  the  performance  of  which  the 
cartilage  is  necessarily  wounded  in  the  formation  of  the  skin  flaps. 

Symptoms. — Following  a  blow  upon  the  ear  or  a  furunculosis  of 
the  external  auditory  meatus,  a  gradual  tumefaction  takes  place  upon 
the  anterior  surface  of  the  auricle.  At  first  the  surface  is  red,  the  local 
temperature  is  elevated,  and  sooner  or  later  the  characteristic  folds  of 
the  convex  surface  of  the  ear  are  obliterated.  Since  this  disease  involves 
only  the  perichondrium,  the  lobule  is  not  included  in  the  swelling.  The 
swelling  is  due  to  the  effusion  of  a  serous  exudate  beneath  the  perichon- 
drium, which  dissects  the  latter  from  the  cartilage  and  creates  a  cavity 
of  varying  size  which  is  completely  filled  with  serum  or  blood.  This 
exudate  may  later  become  infected  and  purulent,  in  which  event  it  will 
finally  rupture  through  the  skin,  leaving  a  discharging  fistula  which  may 
persist  indefinitely.  The  affection  resembles  othematoma,  but  may  be 
diagnosed  from  the  latter  by  its  slower  formation  and  greater  trans- 
parency. In  perichondritis  and  tumefaction  due  to  an  exudate,  if  a 
diagnostic  electric  lamp  be  placed  behind  the  ear  in  a  perfectly  dark 
room  the  tumor  will  be  thoroughly  transilluminated ;  whereas,  in  othema- 
toma, in  which  the  swelling  is  caused  by  a  collection  of  blood  beneath 
the  perichondrium,  the  transillumination  will  show  a  dark  area  over 
the  anterior  site  of  the  tumor. 

Treatment. — Since  unsightly  deformity  will  most  probably  result 
in  any  case  which  is  left  to  nature,  prompt  measures  should  be  instituted 
at  the  earliest  possible  moment  after  the  reception  of  an  injury  to  the 
auricle  which  is  likely  to  result  in  the  affection  in  question.  If  the 
patient  is  plethoric  a  saline  purge  should  be  administered,  the  artificial 
leech  should  be  applied  posterior  to  the  auricle  (see  p.  126),  and  an  ice-bag 

91 


THE    PRINCIPLES    AND    PRACTICE    OF   OTOLOGY 


should  be  subsequently  kept  in  contact  with  the  affected  part  for  twenty- 
four  or  thirty-six  hours.  Since  the  inflamed  and  swollen  auricle  is 
exquisitely  tender,  the  presence  of  the  ice-bag  will  not  be  tolerated  by 
the  patient  unless  the  ear  be  properly  padded  by  placing  a  suitable  roll 
of  cotton  behind  the  auricle.  The  ice-bag  itself  should  be  of  a  size 
much  greater  than  is  necessary  to  cover  the  auricle  and  should  be  only 
partially  filled  with  finely  crushed  ice.  By  the  exercise  of  all  these 
precautions  but  little  weight  will  necessarily  rest  upon  the  affected  part, 
and  therefore  no  considerable  pain  results  from  the  treatment  itself. 

Should  these  early  measures  fail  to  prevent  the  effusion,  surgical 
means  should  be  employed  before  the  exudate  has  spread  and  has 
caused  extensive  separation  of  the  perichondrium  from  the  cartilage, 
an  event  which  may  result  in  death  of  the  latter,  and  consequently 
greater  is  the  liability  to  deformity  of  the  auricle.  At  an  early  date 
and  before  the  effusion  has  become  purulent  the  fluid  may  be  removed 
by  aspiration.  It  usually  returns  immediately,  however,  and  some 
means  of  causing  the  adhesion  of  the  separated  cartilage  and  its  peri- 
chondrium, and  therefore  of  obliteration  of  the  cavity,  should  be  em- 
ployed immediately  after  the  cavity  has  been  thus  evacuated.  For 
this  purpose  a  stiff  wire  spring  may  be  used.  The  auricle  is  padded 
by  one  or  two  layers  of  absorbent  cotton  on  each  side,  and  over  this 
the  expanded  ends  of  the  spring  are  placed  and 
allowed  to  remain  from  twenty-four  to  thirty- 
six  hours.  Care  should,  of  course,  be  exercised 
not  to  cause  sufficient  pressure  to  retard  the 
circulation  in  the  part  and  thus  invite  sloughing 
of  the  affected  area. 

In  most  cases  it  is  better  to  incise  the  tume- 
faction freely  and  by  this  means  most  thoroughly 
evacuate   the   exudate.     When    incised    early  a 
small  iodoform  wick  should  be  inserted  into  the 
cavity  to  serve  as  a  drain,  an  abundance  of  loose 
gauze  is  placed  upon  each  side  of   the  auricle, 
and  a  roller   bandage  is  then    applied   over  all 
with  moderate  pressure.      When  the  exudate  is 
purulent  the  interior  of   the   cavity  should    be 
cureted  with   a  sharp   spoon   in  order  to  clear 
away  all  granulations  and  necrotic  debris;  the  space  is  then  loosely  filled 
with  iodoform  gauze  and  the  dressing  is  completed  as  above  directed. 
Some  deformity  of  the  ear  (Fig.  64)  may  be  expected  in  cases  that 
have  come  late  to  operation,  but  if  in  the  beginning  of  treatment  the 


FIG.  64. — DEFORMITY  OF 
THE  AURICLE  RESULTING  FROM 
TRAUMA. 


DISEASES   OF   THE    AURICULAR   PERICHONDRIUM 


93 


swelling  is  freely  incised  and  is  aseptically  cared  for  afterward,  the  nor- 
mal outline  of  the  auricle  should  usually  be  restored. 


OTHEMATOMA 

Othematoma,  or  hematoma  of  the  auricle,  occurs  as  the  result  of 
an  effusion  of  blood  between  the  perichondrium  and  the  cartilage. 
The  cause  of  such  a  hemorrhage  may  be  either  traumatic  or  spontaneous, 
about  three-fourths  of  all  cases  resulting  from  some  injury  to  the  auricle, 
whereas  about  one-fourth  occur  without  any  assignable  reason.  The 
affection  is  more  frequently  found  upon  the  left  than  upon  the  right  side, 
no  doubt  principally  for  the  reason  that  the  injury  which  causes  it  is 
often  the  result  of  a  blow  from  the  fist  or  open  hand  of  an  opponent 
in  fighting  or  boxing,  and  since  such  blows  are  given  by  the  right  hand 
of  the  antagonist,  the  left  ear  must  inevitably  suffer  most. 

Excepting  professional  boxers,  othematoma  is  probably  more  often 
seen  in  the  insane  than  in  any  other  class.  Occurring  in  those  with 
mental  defect  the  hemorrhage  is  perhaps  as  frequently  of  spontaneous 
origin  as  it  is  due  to  injury,  and  this  frequency  of  spontaneous  hemor- 
rhage has  been  explained  on  the  ground  that  it  is  due  to  tissue  changes 
in  the  auricle,  which  are  somewhat  common 
among  the  insane.  An  ingenious  theory  for 
both  the  tissue  changes  in  the  auricle  of  the 
mentally  degenerate  and  of  the  consequent 
hemorrhage  beneath  the  perichondrium  has 
been  based  upon  the  physiologic  discovery 
of  Brown-Sequard,  to  the  effect  that  a  hemor- 
rhage occurs  in  the  auricle  of  animals  after 
the  restiform  body  has  been  severed. 

Symptoms. — Whether  the  result  of  an 
injury  or  of  spontaneous  effusion,  the  hema- 
toma auris  suddenly  appears  upon  the  anterior 
surface  of  the  auricle  as  an  irregular,  doughy, 
red,  or  bluish-red  swelling,  which  obliterates 
the  underlying  folds  of  skin  and  cartilage 
(Fig.  65).  Othematomata  due  to  injury  are 
usually  larger  than  those  which  result  from  spontaneous  causes.  The 
latter  variety  may  be  multiple.  Either  kind  may  spring  from  the  concha 
or  near  it,  and  when  so  located  the  hearing  is  impaired  because  of  the 
obstruction  thus  offered  to  the  passage  of  the  sound-waves.  When 
located  elsewhere  upon  the  auricle  the  hearing  is  in  nowise  affected  by 


FIG.   65. — CASE  OF   OTHEMATOMA. 
TRAUMATIC.     (Hematoma  auris.) 


94  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

the  swelling.  The  sudden  onset  of  the  hemorrhage  causes  considerable 
tension  upon  the  adjacent  tissues  and  hence  much  pain  is  experienced, 
especially  in  traumatic  cases,  in  which  latter  a  feeling  of  intense  local 
heat  may  be  present  and  add  greatly  to  the  suffering  of  the  individual. 

Diagnosis. — Othematoma  is  liable  to  be  mistaken  for  only  angioma 
of  the  auricle,  new  growths,  or  perichondritis.  Angiomata  and  other 
tumors  of  the  auricle  are  slow  of  growth  and  are  often  many  months 
in  attaining  any  considerable  size,  whereas  the  othematoma  appears 
suddenly.  Perichondritis,  while  of  more  rapid  formation  than  new 
growths  of  the  auricle,  is  nevertheless  much  less  sudden  in  making  its 
appearance  than  is  the  case  when  an  effusion  of  blood  is  responsible 
for  the  auricular  swelling.  The  tumor  following  perichondritis  is  uni- 
formly illuminated  by  transmitted  light,  whereas  transillumination  of 
the  othematoma  shows  a  dark  spot  over  the  area  of  the  blood-clot. 

Treatment. — Small  othematoma  when  of  spontaneous  origin  may 
for  a  time  be  left  to  nature's  process  of  removal  by  absorption,  since 
local  applications,  the  employment  of  compress  bandages,  and  massage 
all  have  a  tendency  to  cause  a  renewal  of  the  hemorrhage  and  hence 
to  increase  the  size  of  the  tumor.  In  case  the  swelling  does  not  disappear 
after  two  or  three  weeks,  and  especially  if  it  should  become  larger,  the 
same  surgical  measures  should  be  employed  that  are  advised  below 
for  the  large  blood-tumor  of  traumatic  origin. 

The  treatment  of  the  recent,  large,  and  painful  othematomata  should 
for  a  few  days  be  expectant.  The  auricle  may  be  coated  with  a  15  per 
cent,  ointment  of  ichthyol,  soft  pads  of  absorbent  cotton  may  be  placed 
on  either  side,  and  an  ice-bag  be  applied  over  all,  as  has  already  been 
directed  in  case  of  traumatic  aural  inflammation.  Should,  however, 
the  pain  and  swelling  show  no  tendency  to  subside  as  the  result  of  this 
treatment  after  its  continuance  for  a  period  of  two  or  three  days,  the 
best  results  will  be  obtained  from  a  free  incision  of  the  swelling  and  the 
complete  removal  of  the  clot.  In  case  the  difficulty  is  of  long  standing 
and  infection  of  the  clot  has  taken  place,  the  cavity  must  be  thoroughly 
cureted  after  the  pus  is  evacuated,  in  order  to  clear  out  all  granulations 
and  necrotic  tissue  that  has  formed.  When  the  injury  which  causes 
the  hemorrhage  of  the  ear  has  been  of  a  severe  nature  the  cartilaginous 
framework  of  the  auricle  is  sometimes  fractured  or  perhaps  comminuted, 
in  which  case  necrosis  of  the  fragments  of  the  cartilage  may  occur.  In 
this  event  any  necrotic  portions  of  the  cartilage  should  be  removed,  along 
with  the  general  riddance  of  all  other  questionable  structures  both  in  and 
about  the  seat  of  the  abscess.  When  the  wound  has  been  cleansed  from 
all  disease,  a  loose  packing  of  iodoform  gauze  is  inserted  and  the  roller 


DISEASES   OF   THE   AURICULAR   PERICHONDRIUM  95 

bandage  is  lastly  employed  with  the  intention  of  securing  moderate 
pressure  upon  both  sides  of  the  auricle.  In  those  instances  in  which 
it  has  been  found  necessary  to  remove  more  or  less  of  the  auricular 
cartilage  during  the  operation,  a  through-and-through  drainage  is  often 
more  efficient  than  that  just  described,  and  this  can  be  secured  by 
lightly  packing  the  wound  with  sterile  gauze  after  a  plan  that  will  allow 
each  end  of  the  strip  to  project  from  each  side  of  the  opening — one  upon 
the  postauricular  surface  and  the  other  upon  the  anterior. 


CHAPTER  VII 


TUMORS   OF   THE   AURICLE 

NEW  formations  of  the  auricle  are  either  of  a  benign  or  malignant 
character.  Of  the  former,  those  most  often  seen  on  the  external  ear 
are  sebaceous  cysts,  fibroma,  papilloma,  and  angioma.  Sarcoma  and 
epithelioma  constitute  the  chief  varieties  of  malignant  growths  in  this 

locality. 

BENIGN   TUMORS    OF    THE   AURICLE 

Sebaceous  Cysts. — This  variety  of  tumor  occurs  most  frequently  on 
the  lobule  or  posterior  to  or  below  the  lobule  (Fig.  66).  It  is  a  variety 
of  retention  cyst,  and  is  the  result  of  an  inflammatory  occlusion  of  the 

mouth  of  one  of  the  sebaceous  glands  and  the 
consequent  accumulation  of  the  normal  seba- 
ceous secretion.  The  size  of  the  resulting 
enlargement  depends  upon  the  amount  of 
sebaceous  material  the  adjacent  structure 
is  capable  of  retaining  before  a  rupture 
through  the  skin  takes  place  and  the  fluid 
is  discharged.  Thus,  if  the  sebaceous  con- 
tents accumulate  slowly  and  the  skin  and 
areolar  tissue  of  the  lobule  are  gradually  put 
upon  the  stretch,  a  tumor  of  considerable 
dimension  may  finally  be  produced.  Should 
a  rupture  occur,  an  intermittent  discharge  of 
thick  creamy  or  cheesy  material  takes  place, 
the  rupture  closes  temporarily,  the  cavity 
refills  and  again  breaks  through,  the  cycle 
being  indefinitely  repeated. 
A  sebaceous  cyst  is  slightly  movable  under  the  skin,  feels  elastic  to  the 
touch,  and  is  not  painful  when  moderately  compressed.  The  tumor 
gives  rise  to  no  pain  or  disturbance  of  any  kind  unless  it  ruptures  and 
discharges.  The  unsightly  appearance  of  deformity  or,  perhaps,  the 
fear  of  malignancy  are  reasons  which  usually  cause  the  individual  to 
seek  the  advice  of  the  surgeon. 

Treatment. — Removal  of  the  tumor  by  surgical  methods  constitutes 

96 


FIG.  66. — CYST  OF  LOBULE  OF 

AURICLE. 

Case  of  Dr.  Wales,  Mass.  Charitable 
Eye  and  Ear  Infirmary. 


TUMORS   OF   THE   AURICLE  97 

the  only  effective  means  of  treatment.  This  may  be  accomplished  under 
local  anesthesia,  Schleich's  plan  being  preferable,  although  freezing  the 
growth  by  means  of  the  ether  spray  or  kelin  may  also  be  employed 
for  this  purpose. 

Following  the  established  rules  of  asepsis  in  the  preparation  of  the 
affected  part  for  the  operation,  an  incision  is  made  through  the  skin 
down  to  the  cyst  wall,  after  which  a  dull  dissector  is  used  and  the  cyst 
is  hulled  out,  if  possible,  without  rupture  of  the  sac  or  the  evacuation  of 
its  contents  Should  the  cyst  have  ruptured  previously  to  the  operation 
or  should  it  be  accidentally  broken  into  during  the  attempt  at  its  removal, 
the  sac  should  be  completely  dissected  out  subsequently  to  the  discharge 
of  its  contents.  When  successful  in  removing  the  cyst  unbroken  or, 
if  ruptured,  if  successful  in  dissecting  the  sac  out  in  its  entirety,  nothing 
further  remains  to  complete  the  operation  except  the  insertion  of  a 
necessary  number  of  sutures  to  accurately  approximate  the  cut  edges 
of  the  wound.  If  the  operator  is  uncertain  as  to  whether  or  not  he  has 
completely  removed  all  the  cystic  walls,  the  interior  of  the  cavity  should 
be  cureted  in  every  direction  by  a  sharp  instrument,  after  which  carbolic 
acid  and  iodin  solution  is  mopped  over  the  interior  and  the  wound 
subsequently  closed  by  sutures  except  at  its  lower  angle.  An  exterior 
pad  of  loose  gauze  and  a  roller  bandage  completes  the  dressing.  Re- 
filling of  the  cyst  does  not  occur  unless  the  sac  or  some  portion  of  it 
has  not  been  removed.  No  deformity  results  from  the  operation. 

Fibroma. — This  class  of  auricular  tumor  may  occur  on  any  portion 
of  the  ear,  but  the  most  usual  site  is  the  lobule.  Race  seems  to  be  an 
important  factor  in  the  causation  of  fibroma,  since  it  is  seen  with  greatest 
frequency  among  negroes.  The  size  of  the  fibroma  may  vary  from  that 
so  small  as  to  be  scarcely  distinguishable  to  a  growth  the  size  of  a  hen's 
egg.  It  is  usually  smooth,  hard,  and  regular  in  outline,  but  may  occasion- 
ally be  nodular  and  even  pedunculated,  the  latter  variety  sometimes 
being  long  enough  to  reach  the  patient's  shoulder.  The  irritation  to 
which  the  lobule  is  subjected  from  wearing  heavy  earrings,  especially 
when  these  are  made  from  base  metals,  constitutes  the  immediate  cause 
of  the  growth  in  many  cases. 

The  prognosis  is  good,  the  tumor  often  persisting  indefinitely  without 
degeneration  and  change  to  a  malignant  nature.  After  the  most  com- 
plete removal  the  tumor  may  return  a  second,  third,  or  even  a  fourth 
time,  and  in  such  instances  may  ultimately  become  malignant. 

Treatment. — Operative  measures  constitute  the  sole  treatment. 
When  the  growth  is  small  and  consequently  produces  no  unsightly 
deformity,  the  rule  should  be  to  allow  it  to  remain  unmolested.  Should 

7 


98  THE    PRINCIPLES   AND    PRACTICE    OF   OTOLOGY 

the  fibroma  be  growing  rapidly  or  should  deformity  result,  its  complete 
removal  should  be  advised.  The  technic  of  the  removal  when  located 
on  the  lobule  consists  in  making  a  V-shaped  incision  over  the  site  of  the 
tumor,  the  apex  of  the  V  pointing  toward  the  concha,  the  angle  and 
length  of  the  two  extremities  of  the  V  depending,  of  course,  upon  the 
size  of  the  growth.  After  the  extirpation  of  the  neoplasm  the  flaps 
should  be  approximated  and  held  in  place  by  fine  catgut  sutures.  When 
fitting  the  flaps  preparatory  to  introducing  the  sutures  a  comparison  of 
the  size  and  shape  of  the  affected  lobule  should  be  made  with  that  of 
its  fellow  of  the  opposite  side,  and  any  redundancy  of  tissue  in  the 
flaps  should  be  trimmed  off  to  an  extent  that  will  insure  a  lobule  which 
is  as  nearly  as  possible  symmetric  with  the  opposite  ear. 

Papilloma. — Benign  epithelial  excrescences  may  spring  from  the 
auricle  either  in  the  form  of  common  warts,  in  which  case  the  growth 
seldom  exceeds  the  size  of  a  split  pea,  or  they  may  be  of  a  conic, 
horn-like  shape,  of  considerable  size,  and  of  a  dense  and  horny  structure. 
Horny  growths  of  the  auricle  have  been  reported  by  Pomeroy l  and  Buck.2 
In  all  4  cases  reported  by  these  two  authors  the  horny  growth  sprang 
from  the  upper  and  posterior  rim  of  the  helix,  varied  in  length  from 
J  to  f  inch,  and  one  was  about  f  inch  in  diameter  at  its  base  of  attach- 
ment to  the  helix.  The  apex  of  the  excrescences  were  dense  and  hard, 
whereas  the  bases  were  of  a  somewhat  softer  structure;  and,  in  Dr.  Pom- 
eroy's  case,  this  portion  of  the  growth  resembled  cartilage. 

The  treatment  consists  in  excision,  and  recovery  without  a  return 
of  the  growth  occurred  in  the  reported  cases.  Common  warts  should 
be  excised  from  their  bases  by  means  of  curved  scissors,  after  which 
the  raw  surfaces  are  immediately  cauterized  with  nitric  acid. 

Angiomata. — Angiomata  are  of  two  kinds — simple  and  cavernous. 
The  former  discolors  the  skin  over  the  site  of  its  location,  but  does  not 
project  from  the  surface  of  the  auricle  in  the  form  of  a  tumor,  whereas 
the  latter  protrudes  from  the  ear  in  the  form  of  a  greater  or  less  nodular 
mass  (Fig.  67).  Angiomata  are  congenital  or  acquired.  When  present 
at  birth  the  auricular  neoplasm  may  be  accompanied  by  similar  angio- 
mata  on  the  face,  jaw,  or  other  parts  of  the  body.  The  cause  of  the 
acquired  variety  is  sometimes  unknown,  but  is  most  usually  attributed 
to  an  injury  of  the  part.  Dr.  J.  M.  Warren  reported  the  case  of  a 
large  angioma  of  the  lobule  which  occurred  twenty  years  subsequent 
to  a  frost-bite  of  the  same  portion  of  the  auricle. 

The  color  of  the  growth  is  reddish  or  bluish.     It  is  usually  soft  and 

' 1  Diseases  of  the  Ear,  p.  52. 
2  Trans.  Am.  Otol.  Society,  1871. 


TUMORS   OF   THE    AURICLE 


99 


yielding  to  the  touch  and  can  frequently  be  emptied  and  temporarily 
reduced  in  size  by  firm  pressure  made  upon  it.  The  affection  is  or  is  not 
painful,  depending  largely  upon  the  rapidity  of  its  development;  for 
in  the  rapidly  growing  tumor  the  tissues  are  rather  suddenly  put  upon 
the  stretch,  thus  causing  a  varying  degree  of  suffering,  whereas  if  of 
slower  growth  there  is  less  tension  of  the  structures  involved  and  conse- 
quently less  pain.  In  cases  of  cavernous 
angioma  the  patient  usually  complains  of 
an  annoying  pulsation  in  the  affected 
auricle. 

Treatment. — When  of  moderate  size, 
removal  of  the  angioma  by  means  of 
electrolysis  is  convenient,  bloodless,  prac- 
tically painless,  and  usually  successful. 
The  platinum  needle  is  attached  to  the 
negative  pole  of  the  battery,  is  passed 
entirely  through  the  base  of  the  tumor, 
and  from  3  to  5  milliamperes  of  current  are 
turned  on.  When  the  parts  overlying  the 
needle  are  whitened,  the  needle  is  with- 
drawn and  reinserted  at  a  distance  of  about 
2  mm.  and  parallel  to  the  first  insertion. 
This  procedure  is  repeated  until  the  whole 
tumor  is  uniformily  whitened,  when,  if  thought  necessary,  the  needle 
may  be  passed  repeatedly  through  the  angioma  at  right  angles  to  the 
previous  insertions. 

The  mass  of  tissue  thus  destroyed  will  slough  out  in  a  few  days 
and  the  wound  will  heal  by  granulation.  Another  and  a  very  successful 
method  is  to  perforate  the  tumor  in  all  directions  with  a  red-hot  needle. 
The  larger  angiomata  may  be  destroyed  by  the  method  first  introduced 
by  Esmarch,  which  is  performed  as  follows:  Small-sized  threads  of 
silk  are  soaked  in  a  solution  of  the  tincture  of  the  chlorid  of  iron,  after 
which  they  are  threaded  into  a  properly  curved  needle  and  passed  en- 
tirely through  the  base  of  the  tumor,  each  being  cut  off  so  as  to  project 
slightly  from  each  side  of  the  growth.  The  threads  should  be  passed 
through  the  base  of  the  angioma  about  2  mm.  apart,  and  are  left  in  posi- 
tion until  coagulation  and  sloughing  has  taken  place.  Two  rows  of 
threads,  introduced  at  right  angles  to  each  other,  may  be  necessary 
to  its  destruction  in  case  the  growth  is  large.  A  light  sterile  dressing 
is  applied  over  the  ear  and  allowed  to  remain  until  separation  of  the 
slough  has  occurred. 


FIG.   67. — ANGIOMA   OF  THE  AURICLE. 
(Hugh    E.  Jones.) 


IOO 


THE    PRINCIPLES    AND   PRACTICE   OF   OTOLOGY 


Treatment  by  the  injection  of  coagulating  fluids  into  this  class  of 
growth,  with  a  view  to  its  destruction,  cannot  be  recommended,  for 
the  reason  that  some  of  the  injected  material  may  directly  enter  the 
blood-current  and  produce  a  dangerous  embolus. 

MALIGNANT    TUMORS    OF    THE    AURICLE 

Malignant  growths  of  the  auricle  are  among  the  rarest  of  the  neo- 
plasms found  in  this  location.  Affections  of  this  nature  may  attack 
any  portion  of  the  auricle,  may  extend  from  the  auricle  into  the  auditory 
meatus,  to  the  face  or  mastoid  region;  or,  on  the  other  hand,  they  may 
begin  upon  the  face  or  in  the  auditory  canal  and  later  spread  to  the 
pinna.  Of  the  two  malignant  diseases  most  commonly  seen  on  the 

auricle — sarcoma    and    epithe- 
<t*fct-  lioma — the  latter  stands  first  in 

_^rtC  point  of  frequency. 

Sarcomata. — Malignant  tu- 
mors of  the  sarcomatous  variety 
rarely  occur  on  the  external  ear. 

(fei  Most  usually  when  found  in  the 

;  V|A  latter  situation  they  are  the  re- 

sult of  an  extension  of  the  dis- 

WH  ease  from  structures  adjoining 

the  auricle  (Fig.  68).  The 
growth  may  be  slow  or  rapid, 
depending  largely  upon  whether 
or  not  it  is  of  the  small,  round- 
cell  variety  or  is  of  the  spindle- 
cell  or  giant-cell  type.  When 
of  round-cell  structure  the  dis- 
ease is  rapid  and  death  has 
been  known  to  occur  as  early 
as  seven  months  from  the  date 

of  the  onset.  On  the  other  hand,  the  spindle-celled  sarcomata  and 
the  fibrosarcomata  may  be  present  on  the  auricle,  as  elsewhere,  for 
years  without  giving  rise  to  the  symptoms  of  disintegration  and  subse- 
quent death  of  the  individual. 

The  diagnosis  is  of  great  importance,  for  the  reason  that  when  the 
nature  of  the  growth  is  determined  at  an  early  date  the  institution  of 
proper  measures  for  treatment  may  not  only  prevent  serious  deformity 
of  the  ear  but  also  the  otherwise  untimely  death  of  the  patient.  The 
diagnosis  is  usually  impossible  in  the  very  earliest  stages,  at  which  time 


FIG.  68. — SARCOMA  AFFECTING  THE  EXTERNAL  AUDITORY 
MEATUS  AND  NEIGHBORING  SOFT  STRUCTURES. 


TUMORS    OF   THE    AURICLE  IOI 

nothing  more  than  the  fact  that  a  tumor  is  present  can  be  ascertained. 
At  this  time  the  integumentary  covering  of  the  growth  is  normal  in 
color,  there  is  little  or  no  pain  on  pressure,  and  the  patient  is  only  aware 
of  the  presence  of  the  tumor  by  having  accidentally  felt  it  or  because 
of  the  slight  deformity  to  which  it  gives  rise.  While  sarcoma  may 
occur  at  any  age,  it  is  more  frequently  seen  in  the  young,  during  that 
time  of  life  when  constructive  tissue  metamorphosis  is  most  active 
(Fig.  68).  Sarcoma  is  unlike  carcinoma  in  the  particular  that  sarcoma 
does  not  usually  involve  the  neighboring  lymphatic  glands,  as  is  the 
case  in  carcinoma.  Round-cell  sarcomata  grow  rapidly  and  there 
soon  appears  over  the  integumentary  covering  a  reddened  or  inflamed 
area  which  quickly  disintegrates  and  leaves  a  raw,  granulating,  highly 
vascular,  and  sometimes  fleshy-looking  surface  that  discharges  a  fetid, 
watery,  or  sanious  fluid.  The  ulceration  extends  both  centrally  and 
peripherally,  and  in  the  worst  cases  involves  not  only  the  auricle  but 
also  the  external  auditory  meatus,  the  parotid  gland,  and  the  osseous 
structures  of  the  temporal  bone.  The  facial  nerve  is  sometimes  included 
in  the  ulcerative  process,  and  as  a  result  of  its  destruction  facial  paralysis 
ensues.  When  a  sarcoma  first  begins  actively  to  disintegrate  and  to 
exhibit  an  angry  inflammatory  redness  over  its  integumentary  surface, 
it  may  be  mistaken  for  a  simple  inflammatory  swelling.  The  brief 
duration  of  a  swelling  of  the  latter  character  and  its  accompanying 
systemic  disturbances  if  taken  into  account  would  serve  to  distinguish 
the  onset  of  an  abscess  from  a  beginning  sarcoma.  The  clinical  evidence 
obtainable  by  a  microscopic  examination  of  a  section  of  the  growth 
should,  when  possible,  he  added  to  that  obtained  from  the  history  of 
the  case  and  the  physical  inspection  of  the  diseased  area. 

Treatment. — Any  tumor  of  the  auricle  or  of  its  immediate  environs 
which  has  remained  quiescent  for  a  considerable  time,  but  which  has 
begun  to  grow  rapidly,  should  be  suspected  of  malignancy  and  should 
therefore  be  excised  at  once.  Caustics,  either  of  a  chemical  or  potential 
nature,  have  no  place  in  the  treatment  of  such  tumors.  If  the  excision 
is  thoroughly  performed  before  superficial  ulceration  takes  place  and 
before  the  deeper  tissues  of  the  ear  and  neck  are  involved,  the  resulting 
scar  will  be  less  and  the  likelihood  of  a  return  of  the  growth  will  be 
greatly  reduced.  In  case  there  is  already  a  widespread  ulceration  and 
the  adjoining  structures,  including  portions  of  the  temporal  bone,  are  in- 
volved, operative  measures  are  often  inadvisable,  and  if  undertaken 
result  in  the  incomplete  removal  of  the  disease,  which,  therefore,  promptly 
returns  should  the  patient  survive  long  enough.  Especially  is  an 
operation  for  removal  not  to  be  undertaken  in  cases  where  the  parotid 


IO2 


THE   PRINCIPLES    AND    PRACTICE    OF   OTOLOGY 


gland  is  greatly  infiltrated,  the  external  auditory  meatus  blocked  by 
ulcerative  products,  and  the  facial  nerve  destroyed,  as  evidenced  by 
the  presence  of  complete  facial  paralysis  of  the  affected  side.  When 
the  disease  affects  only  the  auricle,  external  meatus,  and  adjacent  bone, 
the  growth  may  be  excised  and  the  portions  of  bone  which  are  involved 
may  be  removed  by  following  the  steps — perhaps  in  a  modified  way — 
which  are  necessary  to  the  performance  of  the  radical  mastoid  operation 
(see  Chap.  XXX.).  Temporary  relief  may  be  secured  in  cases  of  this 
latter  kind  when  not  too  far  advanced,  but  ultimate  recurrence  of  the 
growth  and  a  fatal  termination  should  be  expected  in  the  vast  majority. 
Epithelioma. — Epithelioma  sometimes  has  its  beginning  in  the  audi- 
tory canal,  but  more  often  it  originates  on  the  auricle  or  in  the  adjoining 

tissues,  and  later  spreads  to  the 
meatus  (Fig.  69).  Its  pathologic 
histology  differs  in  no  respect  from 
that  found  in  the  same  kind  of 
growth  when  located  elsewhere, 
but  the  symptoms  attendant  upon 
its  development  in  the  ear  are  in- 
fluenced greatly  by  the  local  sur- 
roundings. In  an  auditory  meatus 
that  has  long  been  the  seat  of  an 
irritation  from  eczema,  the  pres- 
ence of  pus,  or  other  similar  affec- 
tions, there  may  develop  an  abra- 
sion accompanied  by  severe  pain. 
This  abrasion  finally  assumes  the 
type  of  an  angry-looking  ulcer; 
gradually  the  pain  takes  on  a  more 
intense  character  and  ultimately 
it  becomes  severe  enough  to  inter- 
fere with  rest  at  night  (see  Fig.  70). 
A  scanty,  foul-smelling  discharge 
occurs,  septic  absorption  from  the 
abraded  surface  takes  place,  ana  the  glands  nearest  the  pinna  are  first 
infiltrated,  and  then  finally  the  whole  chain  of  cervical  lymphatics  may 
become  involved.  Necrotic  sloughs  take  place  in  the  auditory  canal, 
the  normal  structures  of  which  may  thus  be  completely  destroyed;  ulti- 
mately the  disease  spreads  both  deeply  and  widely  until  death  occurs 
from  hemorrhage  or  exhaustion. 

Epithelioma  may  be  mistaken  for  either  sarcoma  or  tuberculosis 


FIG.    69. — EPITHELIOMA   INVOLVING   THE   AURICLE, 

MIDDLE  EAR,  AND  LABYRINTH. 

The  facial  nerve  has  been  destroyed  and  facial  paral- 
ysis is  present.     See  also  Fig.  70. 


TUMORS    OF    THE    AURICLE  103 

of  the  skin.  Epithelioma  occurs  in  those  past  middle  life,  whereas 
both  lupus  and  sarcoma  are  diseases  which  most  usually  appear  in  the 
young.  The  ulcer  which  occurs  in  lupus  is  less  painful  than  that  of 
epithelioma,  and  in  lupus  there  may  be  more  than  one  ulcer  present, 
whereas  in  epithelioma  the  ulcer  is  single.  The  ulcer  of  an  epithelioma 
feels  hard,  its  edges  are  indurated,  everted,  and  whitish;  the  base  is 
rough  and  glazed,  the  secretion  is  comparatively  scanty  and  often  foul 
smelling.  The  edges  of  a  lupus  ulcer  are  soft,  not  everted,  the  floor 
is  smooth  and  granulating,  and  the  exudate  is  abundant  and  free  from 
odor.  A  microscopic  section  of  lupoid  structures  will  show  the  presence 
of  the  tubercle  bacillus;  of  epithelioma,  the  epithelial  structure  and 

r 


FIG.  70. — CARCINOMA  OF  THE  MIDDLE  EAR  AND  MASTOID. 
Advanced  inoperable  case. 

nests;  of  sarcoma,  an  embryonic  structure  of  one  of  three  types  will  be 
found,  namely,  small  round  cells,  spindle  cells,  or  giant  cells. 

Treatment. — When  seen  sufficiently  early  excision  of  the  growth 
may  be  practised,  either  removing  it  by  operating  within  the  auditory 
canal  or  by  detaching  the  auricle  and  cutting  away  all  suspicious  looking 
structures,  including  diseased  portions  of  the  temporal  bone.  If  located 
upon  the  auricle  or  superficially  in  the  auditory  meatus  the  #-ray  should 
be  tried.  When  the  disease  has  become  widely  ulcerated  (Fig.  70)  and 
the  lymphatic  glands  of  the  neck  are  already  infected  by  secondary 
deposits  the  case  is  hopeless,  and  anodynes  administered  internally  and 
soothing  applications  applied  externally  constitute  the  chief  indications 
for  treatment. 


CHAPTER  VIII 
CUTANEOUS   AFFECTIONS   OF   THE   EXTERNAL   EAR 

ECZEMA 

ECZEMA  of  the  auricle,  of  the  external  meatus,  or  of  the  skin  adjoining 
the  auricular  attachment  is  frequently  seen  in  aural  practise.  Because 
of  its  frequency,  the  very  great  suffering  caused  by  the  pruritis  which 
accompanies  the  disease,  and  of  the  tendency  of  the  acute  forms  to  be- 
come chronic,  this  affection  is  considered  of  sufficient  importance  to 
entitle  it  to  a  separate  chapter. 

The  Acute  Form. — An  acute  eczema  usually  begins  at  some  point 
on  the  auricle,  just  within  the  Auditory  canal  or  over  an  area  behind 
the  ear,  usually  that  in  or  adjoining  the  furrow  which  marks  its  attach- 
ment; or  the  whole  auricle,  the  external  meatus,  and  the  adjoining 
integument  may  be  simultaneously  involved. 

Causation. — The  disease  may  be  primary  as  the  result  of  some  local 
irritation  or  it  may  be  secondary  to  constitutional  dyscrasia,  in  which 
latter  instance  the  aural  manifestation  is  likely  to  be  only  a  part  of  a 
more  general  eczematous  eruption.  The  affection  sometimes  arises 
without  any  assignable  cause  whatever,  although  a  previous  local 
irritation  or  some  constitutional  disturbance  is  usually  evident.  Among 
the  local  exciting  agents  productive  of  the  disease  may  be  mentioned 
excessive  heat  or  cold,  as  exposure  to  the  hot  sun,  to  a  low  temperature 
in  winter,  or  to  the  application  to  the  ear  of  heat  or  cold  in  the  form 
of  an  ice-bag  or  hot-water  bottle  for  the  relief  of  pain  during  acute 
aural  inflammation.  The  application  of  certain  remedies  to  the  ear 
has  also  been  followed  by  acute  eczema.  Among  these  may  be  men- 
tioned chloroform  liniments  and  mercurial  or  iodoform  powders  or 
ointments.  An  irritating  aural  discharge,  if  not  promptly  neutralized 
by  frequent  cleansing  of  the  auditory  meatus,  is  one  of  the  most  common 
local  causes  of  eczema. 

The  hooks  of  spectacles,  when  allowed  to  hug  the  ear  too  closely, 
will  in  time  set  up  an  eczema  in  a  susceptible  individual. 

The  constitutional  ailments  that  are  most  productive  of  eczema 
are  the  lithemic  and  rheumatic  diatheses,  struma,  and  rachitis.  When 
due  to  the  first-named  cause  the  individual  is  usually  plethoric,  overfed, 

104 


CUTANEOUS  AFFECTIONS  OF  THE  EXTERNAL  EAR        105 

of  constipated  habit,  and  leads  a  sedentary  life;  whereas  the  strumous 
and  rachitic  classes  who  are  so  affected  are  usually  badly  nourished, 
poorly  housed,  and  are  often  compelled  to  perform  labor  in  excess  of 
their  strength. 

Symptoms. — A  tingling,  burning  feeling  is  first  felt  over  the  affected 
area,  and  this  rapidly  develops  into  a  pruritis  of  such  intensity  that  the 
patient  constantly  desires  to  scratch  and  rub  the  seat  of  inflammation. 
In  the  worst  forms  the  itching  is  so  violent  that  the  patient  is  thereby 
quite  distracted,  and  in  the  effort  to  secure  relief  will  scratch  and  rub 
the  affected  area  so  vigorously  that  the  tissues  are  wounded  by  the 
fingernails  to  the  extent  that  blood  or  serum  oozes  from  every  part  of 
the  inflamed  skin.  At  first  an  erythematous  redness  only  is  seen,  but 
soon  the  color  is  deepened  and  considerable  swelling  takes  place.  This 
is  quickly  followed  by  the  eruption  of  numerous  small  vesicles  which 
are  naturally  short  lived,  but  which  are  commonly  broken  almost  im- 
mediately by  the  vigorous  scratching  of  the  patient  in  his  frantic  efforts 
to  secure  relief.  The  serous  contents  of  the  vesicles,  together  with  the 
subsequent  serous  exudate  from  the  denuded  corium,  constitutes  a 
variety  of  the  disease  commonly  known  as  "  weeping  eczema."  Later 
this  exudate  dries  into  yellowish  crusts,  which  may  be  of  sufficient 
extent  and  thickness  to  obscure  the  folds  of  the  pinna  or  to  block  the 
external  auditory  meatus.  When  not  removed  these  crusts  confine  the 
subsequent  exudate,  which  latter,  becoming  infected,  accumulates 
under  the  crusts  as  a  reservoir  of  pus,  and  in  the  effort  to  liberate  itself 
causes  still  further  erosion  of  the  underlying  tissues.  During  its  con- 
finement under  the  crusts  some  absorption  of  the  pus  may  take  place, 
which  fact  furnishes  an  explanation  for  the  slight  rise  of  temperature 
that  sometimes  accompanies  this  stage  of  the  eczema.  No  disturbance 
to  the  hearing  results  from  the  eczema  unless  the  dried  secretion  and 
desquamated  epithelium,  together  with  the  accompanying  swelling  of 
the  auditory  meatus,  is  sufficient  to  occlude  the  auditory  canal,  or 
unless  the  inflammatory  process  has  involved  the  dermoid  layer  of  the 
tympanic  membrane.  In  either  case  a  varying  though  usually  moderate 
degree  of  deafness  may  be  present. 

Prognosis. — The  mildest  forms  of  acute  eczema  will  run  the  entire 
course  of  hyperemia,  vesiculation,  and  desquamation,  and  the  recovery 
be  complete  within  a  few  days.  In  this  type  of  case  the  vesicles  do  not 
rupture,  exudation  does  not  take  place  upon  the  skin,  and  the  epidermis 
is  subsequently  shed  in  the  form  of  fine  branny  scales.  The  deeper 
skin  structures  not  having  been  involved,  subsequent  thickening  of  this 
structure  does  not  occur.  Most  cases  are,  however,  not  so  fortunate. 


IO6  THE    PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 

The  vesicles  go  on  to  rupture  or,  as  most  usually  happens,  are  scratched 
open,  the  deeper  structures  are  at  the  same  time  lacerated,  and  the 
disease  runs  its  whole  course  of  crust  formation  and  pustulation;  deeper 
desquamation  then  follows,  requiring  several  days  or  even  weeks  in  the 
worst  cases  for  the  completion  of  the  process  and  a  return  to  the  normal. 
When  some  constitutional  disease  has  been  the  chief  causative  agent  in 
the  production  of  the  acute  eczema  a  continuance  of  the  disease  into 
the  chronic  form  is  often  observed.  Frequent  relapses  may  be  expected 
in  any  case,  and  an  individual  who  has  once  suffered  from  an  eczema 
is  thereby  predisposed  to  future  attacks. 

Treatment, — The  successful  management  of  this  disease  must  be  upon 
a  plan  that  will  correct  the  continued  action  of  the  causative  systemic 
or  local  irritant  upon  the  affected  parts.  This  should  include  that  plan 
of  medication  which  is  the  most  soothing  to  the  actively  inflammatory 
state  of  the  skin  and  to  its  highly  excitable  and  oversensitive  nerve- 
endings.  The  use  of  pure  water  for  any  purpose  upon  an  acute  eczema- 
tous  area  usually  acts  as  an  additional  irritant  and  should,  where  possible, 
be  withheld.  If  an  aural  discharge  is  present  it  is  better,  therefore,  to 
mop  the  entire  auditory  canal  with  cylinders  of  cotton  after  the  manner 
already  given  (see  p.  340)  rather  than  to  cleanse  the  canal  by  syringing. 
Dry  cleansing  should  be  done  often  enough  to  prevent  the  accumulation 
of  acrid  secretions  upon  any  part  of  the  auditory  canal.  If  it  becomes 
necessary  to  syringe  an  eczematous  ear  for  the  purpose  of  removing 
dried  crusts  from  the  meatus  or  irritating  discharges  from  the  middle  ear, 
the  fluid  best  suited  for  this  purpose  is  one  to  which  5  gr.  of  sodium  bicar- 
bonate to  i  ounce  of  water  has  been  added,  and  if  severe  itching  is  pres- 
ent, the  addition  of  i  or  2  per  cent,  carbolic  acid  is  indicated.  Demul- 
cent solutions,  like  oatmeal  or  slippery  elm  water,  are  also  grateful  to  the 
acutely  inflamed  skin,  and  may  be  substituted  for  the  alkaline  solution 
if  that  should  prove  irritating.  Each  time  after  thus  thoroughly  re- 
moving all  pus  from  the  channel,  a  small  quantity  of  calomel  or  bismuth 
subnitrate  may  be  blown  into  the  auditory  canal  or  may  be  dusted  over 
any  moist  surface  upon  the  concha  or  pinna  Powders  thus  employed 
should  be  known  to  be  pure  and  free  from  lumps.  Other  impalpable 
non-irritating  powders  of  greatest  value  as  protective  agents  are  starch, 
rice  flour,  talcum,  oxid  of  zinc,  and  lycopodium.  Under  no  circum- 
stances is  it  wise  in  case  of  eczema  of  the  meatus  to  introduce  large 
quantities  of  any  kind  of  powder,  for  the  reason  that  so  soon  as  it  is 
saturated  by  the  pus  or  eczematous  exudate  it  forms  into  hard  crusts, 
which  will  block  the  channel  and  retain  the  secretions  unless  the  ob- 
struction be  quickly  removed;  and  it  should  be  remembered  that  the 


CUTANEOUS  AFFECTIONS  OF  THE  EXTERNAL  EAR        107 

removal  of  such  masses  is  often  accomplished  with  some  difficulty. 
When  the  itching  is  intense  and  the  parts  feel  hot  to  the  patient,  especially 
when  the  whole  auricle  appears  greatly  swollen  and  the  exudate  is  very 
profuse,  the  application  of  a  wash  of  subacetate  of  lead  and  opium 
proves  efficacious  in  many  instances: 

R.  Tinct.  opii,  3ss; 

Liquor  plumbi  subacetate,  dilute,  q.  s.  ad.  3viij. — M. 

A  valuable  astringent  and  sedative  lotion  may  also  be  obtained  by 
combining  lime-water  and  carbolic  acid  in  proper  proportions  to  meet 
the  requirements  of  the  individual  case.  Thus  the  following  combina- 
tion may  be  modified  and  made  suitable  to  the  individual  by  either 
increasing  or  decreasing  the  amount  of  phenol,  which,  as  a  rule,  should 
not  exceed  i  dr.  to  i  pint: 

K  .  Carbolic  acid,  gr.  xl ; 

Zinc  oxid,  3J! 

Glycerin,  ^iv; 

Aquse  calcis,  q.  s.  ad.  3~viij. — M. 

It  is  highly  essential  to  successful  treatment  that  some  means  be  devised 
to  prevent  the  patient  from  constantly  lacerating  his  ear  with  his  finger- 
nails in  an  effort  to  allay  the  itching.  Success  in  this  direction,  especially 
in  children,  is  most  certainly  attained  by  first  applying  the  local  medica- 
tion that  is  chosen,  then  covering  the  ear  with  a  thick  pad  of  sterile 
gauze,  and  finally  finishing  the  dressing  by  the  application  of  a  roller 
bandage  about  the  head,  exactly  as  is  done  in  the  completion  of  a  mastoid 
dressing  (see  p.  396,  Fig.  255).  Owing  to  the  untiring  efforts  which 
the  patient  will  sometimes  make  in  rubbing  the  itching  part  through 
this  dressing,  the  same  will  be  quickly  dislodged  unless  extra  care  is 
bestowed  upon  its  application.  The  use  of  long  strips  of  adhesive 
plaster  to  fasten  the  separate  turns  of  the  bandage  as  they  are  applied 
to  the  head  is  a  method  to  be  recommended  in  this  particular  dressing. 
Ointments  or  oils  frequently  act  better  than  powders  or  lotions, 
especially  when  the  acute  is  passing  to  the  subacute  stage.  In  general, 
it  may  be  said  that  when  the  parts  are  intensely  inflamed,  burning  and 
itching,  in  the  very  beginning,  and  therefore  before  the  onset  of  the 
desquamative  stage,  that  the  lotions  here  given  may  be  used  with  good 
results.  When  the  amount  of  the  exudate  is  considerable  but  not  pro- 
fuse, the  drying  powders  prove  most  beneficial.  When  there  is  infiltra- 
tion of  the  skin,  when  crusts  have  formed,  and  underlying  these  the 
skin  is  denuded,  zinc  oxid  or  other  non-irritating  ointment  has  proven 
highly  satisfactory.  Carron  oil,  when  prepared  from  equal  parts  of 
fresh  lime-water  and  pure  olive  oil,  constitutes  a  preparation  that  is 


IO8  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

non-irritating  and  hence  quite  grateful  and  efficacious  in  cases  where 
protection  of  the  acutely  inflamed  part  is  chiefly  indicated ;  i  per  cent,  of 
phenol  may  be  advantageously  added  to  this  preparation  if  severe 
pruritis  is  present.  The  solution  may  be  applied  to  the  auditory  canal 
and  auricle  by  means  of  a  cotton-tipped  applicator,  after  which  liberal 
pads  of  gauze  are  placed  over  the  ear  and  a  roller  bandage  applied, 
as  above  directed.  In  subacute  cases,  after  the  crusts  that  have  been 
formed  by  the  drying  of  the  exudate  have  been  removed  or  after  they 
have  ceased  to  form,  solutions  of  silver  nitrate  are  without  question 
often  of  service  in  reducing  the  thickness  of  the  infiltrated  walls  of  the 
auditory  meatus,  and  thus  in  restoring  the  lumen  of  the  auditory  canal 
to  its  normal  dimensions.  Silver  occasionally  aggravates  the  trouble 
if  used  in  too  concentrated  solution  at  first.  Hence  in  the  beginning 
not  more  than  10  or  15  gr.  to  i  ounce  should  be  tried,  but  a  greater 
concentration  may  be  employed  later  if  the  remedy  is  well  tolerated. 
The  best  effects  are  usually  observed  when  gr.  xl  to  gr.  Ixxx — Ij 
are  used. 

Any  plan  of  treatment  which  does  not  include  careful  attention  to 
the  general  system  of  the  patient  will  fail  in  a  large  number  of  cases. 
In  eczematous  children  it  is  frequently  found  that  the  diet  is  faulty; 
that  sweets,  nuts,  and  pastry  have  too  largely  replaced  the  substantial 
foods,  and  that  stomach  and  intestinal  derangements  are  present  to  an 
extent  of  being  largely  causative  of  the  aural  or  general  eczema.  Seden- 
tary adults  who  eat  too  liberally  of  nitrogenous  foods  and  partake  too 
much  of  beer  or  wine  are  subjects  of  a  considerable  number  of  ailments — 
of  which  eczema  is  one — that  are  commonly  covered  by  the  terms 
lithemia  or  gout.  Correction  of  these  errors  when  found  will  usually 
go  far  toward  a  cure  of  the  skin  trouble  at  the  time,  and  also  toward 
its  prevention  and  subsequent  recurrence.  An  occasional  dose  of  the 
mild  chlorid  of  mercury  at  night,  followed  by  a  brisk  saline  cathartic 
on  the  following  morning,  is  of  value.  Where  lithemia  is  clearly  present, 
the  continuous  administration  of  citrate  of  lithia  for  several  weeks,  in 
large  draughts  of  pure  water,  is  beneficial  in  ridding  the  system  of  the 
uric-acid  irritant.  Salicylate  of  methyl  in  combination  with  colchicin 
will  give  excellent  results  in  cases  of  rheumatic  habit  or  where  there 
is  a  tendency  for  the  eczema  to  become  chronic.  Arsenic  should  never 
be  administered  in  acute  eczema.  The  tubercular  and  rachitic  cases 
must  receive,  in  addition  to  the  local  medication,  the  general  treatment 
appropriate  for  each  of  these  diseases. 

Chronic  Eczema. — The  chronic  form  results  invariably  from  the 
acute  variety,  and  may  persist  for  months  or  throughout  the  individual's 


CUTANEOUS  AFFECTIONS  OF  THE  EXTERNAL  EAR 


109 


life.  When  once  the  chronic  stage  has  been  reached  the  affected  area 
remains  dry,  except  during  acute  exacerbations.  The  inflammatory 
process,  \vhich  persists  for  a  long  time  in  the  cutis  and  sometimes  in 
the  underlying  connective  tissue,  results  finally  in  an  infiltration  and 
ultimate  hyperplasia  of  all  the  structures  involved.  Hence  the  lumen 
of  the  auditory  meatus  becomes  narrowed  and  the  auricle,  if  this  be 
implicated,  assumes  a  thickened,  shiny  appearance,  and  has  a  leathery 
feel.  The  epithelial  covering  of  the  affected  parts  is  constantly  shed 
before  the  cells  mature,  and  their  accumulation  in  the  form  of  dry  branny 
scales  sometimes  blocks  the  meatus  completely;  or  if  pus  or  other  secre- 
tion is  present,  a  foul-smelling  epithelial  plug  is  found  filling  the  audi- 
tory canal. 

While  itching  is  seldom  so  violent  as  in  the  acute  variety,  it  is  never- 
theless commonly  present,  and  during  the  acute  exacerbations  of  the 
chronic  form  may  be  very  severe.  The  pruritus  leads  the  patient  to 
pick  at  his  ears  with  a  match,  toothpick,  or  any  convenient  object  that 
is  small  enough  to  enter  the  canal,  with  the  unfortunate  result  of  oc- 
casionally producing  an  acute  circumscribed  or  even  a  diffuse  external 
otitis,  a  full  description  of  which  is  given  elsewhere  in  this  section 
(see  Chapter  IX.). 

As  a  consequence  of  the  long-continued  inflammation  of  the  integu- 
ment of  the  auditory  canal  the  ceruminous  glands  may  be  atrophied  or 
destroyed  to  an  extent  that  the  ear-wax  is  only  scantily  or  not  at  all 
secreted;  and  without  this  natural  emollient  dressing  the  canal  finally 
becomes  dry  and  presents  a  horny  aspect,  with  sometimes  a  fissure 
which  extends  entirely  through  the  integumentary  thickness. 

Treatment. — This  form  of  aural  disease  is  usually  quite  difficult 
to  treat  in  an  entirely  satisfactory  manner.  The  long  list  of  remedies 
that  are  recommended  by  various  authorities  if  given  here  would  only 
confuse  the  student  and  would  more  than  likely  lead  to  an  unfortunate 
choice  in  any  given  case.  Hence  it  is  thought  best  to  present  only  a 
few  that  have  proven  in  the  author's  experience  more  satisfactory  than 
the  rest,  and  to  outline  the  circumstances  under  wThich  the  same  should 
be  applied. 

In  chronic,  dry,  and  scaly  skin  affections  arsenic  has  long  been  used, 
has  proved  of  value,  and  is  a  proper  remedy  for  internal  administration. 
A  convenient  preparation  for  this  purpose  is  Fowler's  solution,  which 
may  be  given  to  the  amount  of  10  or  15  drops  daily,  but  this  should  be 
immediately  withheld  should  an  acute  exacerbation  of  the  eczema 
appear.  The  value  of  arsenic  administered  internally  is  probably 
best  exemplified  in  cases  in  which  the  eczema  is  to  some  extent,  at  least, 


110  THE    PRINCIPLES  AND    PRACTICE   OF   OTOLOGY 

dependent  upon  a  neurotic  or  trophic  derangement.  The  remedy 
should  never  be  given  indiscriminately,  that  is,  simply  because  a  given 
patient  is  suffering  from  a  chronic  eczema.  The  individual  case  should 
always  be  studied  in  every  particular,  and  arsenic  be  given  only  in 
those  in  whom  it  is  positively  determined  the  remedy  is  not  contra- 
indicated.  Sole  dependence  in  the  treatment  of  eczema  should  never 
be  placed  on  arsenic,  for  in  the  most  favorable  cases  it  can  only  be 
regarded  as  one,  and  often  the  least  important,  of  the  means  of  cure. 
In  this  as  in  the  acute  form,  scrofula,  lithemia,  rickets,  anemia,  etc., 
may  be  entirely  responsible  for  the  continuance  of  the  local  disease, 
and  each  case  must,  therefore,  be  studied  with  a  view  to  learning  the 
causative  element  and  of  rectifying  the  same  according  to  the  rules 
laid  down  in  treatises  devoted  to  the  practise  of  modern  medicine. 

The  local  treatment  should  be  directed  toward  securing  comfort  to 
the  patient,  toward  arresting  the  progress  of  the  disease  if  possible, 
and  toward  removing  the  infiltrated  and  thickened  condition  of  the 
affected  parts.  For  the  relief  of  the  itching  of  the  auditory  meatus 
the  author  has  used  no  remedy  that  has  proved  so  efficient  and  lasting 
in  its  affects  as  the  combination  of  carbolic  acid  and  iodin  dissolved  in 
rectified  spirits: 

R.   Iodin  (crystals),  gr.  x  ; 

Carbolic  acid,  gr.  x. 

Rectified  spirits,  3J. — M. 

The  auditory  meatus  should  first  be  cleansed  by  removing  all  loose 
epithelial  masses,  after  which  the  walls  of  the  canal  are  painted  with  the 
above  preparation  by  means  of  a  cotton-tipped  applicator.  In  order  that 
only  a  small  quantity  of  the  solution  shall  be  carried  to  the  affected  parts, 
the  amount  of  cotton  used  for  covering  the  tip  of  the  applicator  should 
be  small,  and  after  it  is  dipped  into  the  liquid  any  excess  must  be  re- 
moved by  lightly  rolling  the  end  of  the  instrument  which  carries  the 
medicament  on  a  piece  of  blotting-paper.  Until  the  degree  of  tolerance 
the  patient  may  have  for  this  remedy  is  established,  it  is  wise  to  apply 
the  iodin-carbolic  mixture  rather  sparingly.  A  single  application 
frequently  controls  the  itching  for  several  days  or  even  weeks,  during 
which  period  other  measures  of  a  general  or  local  therapeutic  value 
may  be  carried  out. 

Bellamy  uses  to  good  advantage  on  other  parts  of  the  body  a  some- 
what similar  iodized  fluid  for  the  relief  of  papular  patches  of  chronic 
eczema  of  an  obstinate  nature. 

Contrary  to  the  rule  that  has  been  given  for  the  treatment  of  acute 


CUTANEOUS  AFFECTIONS  OF  THE  EXTERNAL  EAR        III 

eczema,  in  the  management  of  the  chronic,  infiltrated  varieties,  the  best 
results  are  obtained  from  stimulating  applications.  Hence,  where  the 
skin  is  greatly  thickened,  fissured,  or  even  widely  ulcerated,  these  path- 
ologic states  often  subside  under  the  daily  application  of  green  soap, 
followed  by  vigorous  rubbing  with  a  coarse  cloth,  or  even  by  scrubbing 
the  same  with  a  brush.  When  used  in  the  external  auditory  meatus 
the  soap  is  inserted  with  the  finger  and  afterward  vigorously  rubbed 
into  the  skin  with  a  cotton-tipped  applicator.  The  rubbing  should 
be  continued  for  several  minutes,  following  which  the  excess  of  soap 
is  syringed  away  and  a  zinc  oxid  dressing  immediately  applied.  This 
process  may  be  repeated  daily  or  even  twice  daily  with  the  most  satis- 
factory results,  and  is  omitted  only  when  the  abraded  surfaces  are  all 
healed  and  the  thickness  of  the  affected  skin  has  been  sufficiently  reduced. 
Another  stimulating  treatment  that  has  proved  valuable  is  the 
application  of  the  oil  of  rusci,  properly  combined  in  the  form  of  an 
ointment : 

li.  Ol.  rusci,  3i~ij> 

Potass,  subcarb.,  ^J! 

Unguent,  aquae  rosas,  5J. — M. 

This  is  rubbed  into  the  chronically  inflamed  and  thickened  parts  three 
times  a  week,  after  first  having  cleared  the  meatus  of  all  epithelial 
debris.  In  beginning  the  application  of  the  tar  preparations,  like  that 
of  the  oil  of  rusci  given  above,  it  is  not  wise  to  use  the  full  strength,  for 
the  reason  that  it  may  prove  too  stimulating,  and  an  acute  exacerba- 
tion of  the  eczema  will  result.  Until  tolerance  is  established  it  is  better, 
therefore,  to  dilute  the  preparation  one-half  or  more,  using  zinc  oxid 
ointment  for  that  purpose.  Bench  highly  praises  the  vinegar  of  can- 
tharides,  the  local  use  of  which  in  these  cases  he  states  will  very 
rapidly  deplete  the  parts  and  effect  a  disappearance  of  the  excessive 
deposit  of  inflammatory  tissue. 

Whatever  method  of  treatment  is  chosen,  much  time  will  be  required 
in  accomplishing  all  that  may  be  desired.  Should  acute  symptoms 
develop  at  any  time,  all  stimulating  treatment  must  be  withdrawn,  and 
the  soothing  applications  which  have  been  recommended  as  proper 
for  the  acute  forms  of  eczema  should  be  temporarily  substituted.  One 
remedy  may  act  satisfactorily  for  a  time  in  a  given  case,  but  afterward 
may  become  inert  or  even  harmful,  and  hence  in  the  course  of  the  treat- 
ment it  is  often  found  necessary  to  change  from  one  to  another  plan,  or 
even  to  let  the  patient  rest  from  all  treatment  for  a  few  days  or  weeks. 


112  THE    PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 

NOMA 

Noma  of  the  fibrocartilaginous  canal,  the  auricle,  and  the  surround- 
ing region  is  a  form  of  gangrene  of  the  ear  similar  to  gangrene  of  the 
face  and  genitals,  and  occurs,  as  a  rule,  in  poorly  nourished  children 
during  infancy  and  early  childhood.  The  disease  is  rare  and  begins 
in  or  around  the  ear.  The  ulceration  rapidly  spreads,  attacking  the 
parotid  and  mastoid  regions,  often  with  destruction  of  the  auricle 
(Fig.  71). 

The  following  report  of  a  case  of  noma  by  Verhoeff  (Journal  o] 
the  Boston  Society  o]  Medical  Science,  vol.  v.,  May,  1901)  is  interest- 


FlG.    71. — XOMA  OF  THE  RlGHT  At'RICLE  IN  A  CHILD  OF   FlVE  MONTHS. 

The  gangrenous  ulceration  involves  the  tragus  and  lobule  of  the  ear,  a  portion  of  the  cheek,  and  extends 
into  the  external  auditory  meatus.  A  similar  but  less  extensive  process  is  present  on  the  other  side.  Photo- 
graph taken  six  hours  after  death.  (Verhoeff.) 

ing  and,  together  with  his   comments,  gives   a   good    expose    of    the 
existing  knowledge  concerning  this  disease: 

Infant,  aged  five  months,  admitted  January  16,  1901.  Family  his- 
tory unimportant.  Previous  history,  always  well  and  strong  until 
present  illness.  For  five  weeks  previous  to  admission  there  was  a  dis- 
charge from  each  ear.  One  week  previous  to  admission  the  parents 
noticed  that  on  the  right  side  the  discharge  was  irritating  the  skin  of 
the  external  auditory  canal  and  lobule  of  the  ear.  On  admission  there 
was  a  purulent  discharge  from  both  ears,  the  tympanic  membranes 
were  partially  destroyed,  and  just  in  front  of  and  below  the  lobule  of 
the  right  ear  there  was  a  deep  round  ulcer,  7  mm.  in  diameter,  with 
irregular  base  and  slightly  overhanging  edges.  The  base  of  the  ulcer 
was  covered  with  pus.  The  surrounding  parts  were  red  and  thickened. 
The  left  ear  showed  no  ulceration,  but  on  the  helix  there  were  two  or 


CUTANEOUS  AFFECTIONS  OF  THF  EXTERNAL  EAR        113 

three  reddened  spots.  Despite  treatment  by  the  actual  cautery  and 
local  applications  of  antiseptics,  the  ulcerative  process  on  the  right 
side  gradually  spread,  involving  the  cheek;  and  on  the  fifth  day  after 
admission  there  was  also  a  definite  ulcer  just  below  the  left  auricle. 
On  the  seventh  day  there  was  noted  on  the  right  side  near  the  ulcer 
a  reddened  area  about  1.4  cm.  in  diameter,  but  the  ulcer  seemed  to 
spread  by  direct  extension  into  sound  tissue.  On  the  seventh  day  it 
was  also  noticed  that  the  left  great  toe,  and  to  a  less  extent  the  little 
finger  of  the  right  hand,  were  red  and  swollen.  On  succeeding  days 
other  joints  of  the  fingers  and  toes  became  affected  in  the  same  way. 
The  appearance  of  some  of  the  joints  would  vary  greatly  even  during 
the  course  of  one  day,  now  appearing  more  and  now  less  inflamed. 
The  same  thing  was  observed  in  the  case  of  the  reddened  area  near 
the  ulcer  of  the  right  ear,  which  for  two  days  became  almost  invisible, 
and  then  again  reappeared  as  a  much  larger  area  with  an  ill-defined 
border.  There  was  diarrhea  and  the  child  took  its  nourishment 
poorly.  Both  the  local  and  general  condition  of  the  patient  steadily 
became  worse,  and  the  child  finally  passed  into  a  semicomatose  con- 
dition and  died  on  the  seventeenth  day  after  admission. 

Autopsy  by  Dr.  Verhoeff,  twelve  hours  after  death: 

Diagnosis. — Streptococcus  otitis  media  and  mastoiditis,  strepto- 
coccus gangrenous  ulceration  of  the  auricles  and  cheeks,  streptococcus 
synovitis,  streptococcus  bronchopneumonia,  streptococcus  septicemia, 
croupous  colitis. 

Verhoeff  believed  there  was  little  question  that  the  gangrenous 
ulceration  of  the  auricles  and  cheeks  was  the  result  of  infection  by  the 
purulent  discharge  from  the  middle  ear.  When  it  is  considered  that 
the  streptococcus  is  commonly  found  in  otitis  media,  it  seems  remark- 
able that  such  an  infection  does  not  occur  more  often.  In  noma  of 
the  mouth  there  is  usually  a  history  of  some  previous  disease,  often 
one  of  the  exanthemata,  but  in  this  case  no  such  history  could  be 
obtained,  thus  rendering  the  infection  less  easy  to  explain  on  the 
grounds  of  lowered  resistance.  It  is  possible  that  the  virulence  of  the 
organism  is  a  more  important  factor  than  the  lack  of  resistance  of  the 
patient.  The  streptococcus  septicemia,  synovitis,  and  pneumonia, 
while  not,  of  course,  alone  sufficient  to  prove  the  nature  of  the  infec- 
tion in  the  local  ulcers,  nevertheless  are  highly  confirmatory  in  this 
regard,  and,  in  addition,  indicate  either  that  the  patient  possessed  very 
little  resistance  toward  the  streptococcus  or  that  the  latter  was  ex- 
tremely virulent. 

Verhoeff  was  able  to  find  13  cases  of  noma  auris  in  the  literature; 

8 


114  THE    PRINCIPLES   AND    PRACTICE    OF   OTOLOGY 

most  of  them  very  incompletely  reported.  The  ages  varied  from  three 
weeks  to  four  years;  8  cases  were  associated  with  otitis  media,  while  in 
the  remaining  cases  no  mention  was  made  of  this  disease,  although  in 
some  of  them  it  was  no  doubt  present.  In  3  cases  the  affection  was 
bilateral.  Death  resulted  in  all  but  i  case,  that  of  Hutchinson,  who 
cauterized  the  ulcer  with  acid  nitrate  of  mercury.  None  of  the  cases 
were  investigated  histologically,  and  but  i  of  them  bacteriologically. 
The  latter  was  reported  by  G.  M.  Smith,  wrho  obtained  from  the  ulcer 
of  the  auricle  and  from  the  longitudinal  sinus  cultures  of  a  short  non- 
motile  bacillus  with  rounded  ends,  often  arranged  in  pairs  or  chains. 

LUPUS    OF   THE    EAR 

Tubercular  infection  of  the  skin  of  the  external  ear  may  be  classed 
among  the  rarer  affections  of  this  appendage.  The  disease  may  involve 
both  auricles,  but  usually  only  one.  Lupus  is  a  disease  occurring 
most  frequently  in  early  life,  at  a  time  when  the  developmental  changes 
of  the  skin  are  most  active,  and,  therefore,  no  doubt  on  this  account  it 
is  more  susceptible  to  attack  by  the  tubercle  bacillus.  The  cutaneous 
infection  may  be  the  result  of  the  direct  contact  of  the  tubercular  bacilli, 
or  it  may  be  secondary  to  a  general  infection  in  which  the  lungs,  bones, 
or  glandular  system  have  been  previously  involved.  Two  varieties  of 
lupus — namely,  lupus  erythematosus  and  lupus  vulgaris — are  those 
most  frequently  found  upon  the  external  ear. 

Lupus  Erythematosus. — This  variety  is  much  the  milder  of  the 
two  affections,  and  is  perhaps  most  usually  found  associated  with, 
rather  than  an  integral  part  of,  the  tubercular  affection  which  constitutes 
the  entire  essential  pathology  of  lupus  vulgaris.  Lupus  erythematosus 
occurs  most  frequently  upon  the  lobule  of  the  ear,  from  which  point  it 
may  spread  in  every  direction  and  ultimately  involve  the  whole  auricle, 
and  possibly  the  adjacent  skin  of  the  face  and  neck.  On  the  other 
hand,  the  lupus  may  begin  on  the  face  or  neck  and  subsequently  extend 
to  the  auricle. 

Symptoms. — Lupus  erythematosus  begins  as  a  small  reddish  macule 
upon  the  surface  of  the  skin,  which  is  slightly  elevated  over  the  affected 
area.  This  macule,  in  due  course  of  time,  enlarges,  and  after  a  period 
of  many  months  or  even  years  may  involve  more  or  less  of  the  entire 
auricle  and  corresponding  side  of  the  face.  These  patches  of  lupus 
are  of  bright  red,  pinkish,  or  purplish  color,  and  are  of  a  somewhat 
circular  or  ovoid  shape.  After  a  long  persistence  of  the  discs  the  center, 
or  point  of  origin  of  the  lupus,  becomes  slightly  depressed  and  faded, 
and  in  the  very  old  cases  the  activity  of  the  lupoid  process  ceases  at  the 


center,  leaving  characteristic  white  scars  surrounded  by  a  slightly  elevated 
rim  of  advancing  disease.  From  the  beginning  the  macules  are  covered 
with  white  or  yellowish- white  scales  which  are  slightly  adherent,  their 
under  surfaces  sometimes  having  root-like  projections  which  extend 
into  the  mouths  of  the  underlying  sebaceous  glands. 

The  disease  is  most  frequent  between  the  twentieth  and  fortieth 
year.  When  unchecked  by  treatment  it  often  continues  through  the 
balance  of  the  individual's  life.  Although  characterized  by  this  remark- 
able persistency,  lupus  erythematosus  is  a  disease  which  usually  does 
not  produce  serious  pain,  itching,  or  other  bodily  discomfort,  and  may 
not  at  any  time  during  its  long  course  interfere  with  the  general  health 
of  the  patient.  The  mental  anguish  due  to  disfigurement  of  the  face 
and  ear  constitute,  therefore,  the  most  serious  aspect  of  the  affection. 

Diagnosis. — The  history  of  the  onset  and  long  continuance  of  the 
disease  furnish  strong  data  for  a  positive  diagnosis.  The  character  of 
the  scales  which  cover  the  discs,  the  elevated,  circular,  advancing 
margin  of  the  affection,  and  the  coexisting  depressed,  pale,  or  scar-like 
center  of  the  same,  taken  as  a  whole,  constitute  a  condition  found  in 
no  other  disease. 

Treatment. — The  fact  that  scores  of  remedies  or  combinations  of 
remedies  have  been  recommended  for  the  cure  of  this  disease  clearly 
indicates  its  incurability  or,  at  least,  the  difficulty  of  cure  by  local  me- 
dicinal means.  The  very  acute  forms  of  lupus  erythematosus  should  be 
treated  by  the  most  soothing  local  applications,  such  as  have  already 
been  recommended  for  the  first  stages  of  acute  eczema  (see  p.  106). 
Chronic  and  indolent  forms  of  this  variety  of  lupus  are  more  satisfactorily 
managed  by  stronger  applications,  the  following  being  one  of  the  best: 

R.   Ichthyol,  3ss; 

Collodii,  3v. — M. 

This  combination  should  be  painted  over  the  affected  area  and  reapplied 
as  often  as  it  loosens  and  peels  from  the  skin.  If  found  too  irritating, 
the  quantity  of  ichthyol  may  be  lessened,  whereas  in  the  very  indolent 
cases  advantage  will  be  gained  by  increasing  the  proportion  of  ichthyol. 
Destructive  agents  are  sometimes  necessary  and  have  been  frequently 
used  in  the  past.  Of  these  lactic  acid,  trichloracetic  acid,  and  pyrogallic 
acid  are  preferable.  Agents  of  this  class  have  recently  been  superseded 
by  the  methods  of  phototherapy  and  radiotherapy,  and  since  the  results 
of  treatment  by  these  means  are  more  favorable  than  those  from  the 
use  of  chemical  agents,  the  former  should  be  recommended  in  any  case. 
As  has  already  been  stated,  most  cases  of  lupus  erythematosus  occur 


Il6  THE   PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 

in  persons  who  are  otherwise  in  good  health.  In  these  general  medica- 
tion is  not  called  for.  When  associated  with  tuberculosis,  scrofula,  or 
other  cachectic  affection,  internal  remedies  which  are  proper  for  the 
associated  general  disease  should,  of  course,  be  included  in  any  plan 
of  treatment.  Personal  hygiene  and  physical  exercise  in  the  open  air 
are  quite  as  essential  to  success  as  any  form  of  medication. 

Lupus  Vulgaris. — This  affection  is  a  true  tuberculosis  of  the  skin. 
Like  the  preceding  disease  it  may  begin  on  the  auricle — usually  on  the 
lobule — and  later  cover  the  whole  external  ear  and  auditory  canal,  or 
it  may  spread  to  the  ear  from  the  neighboring  skin  of  the  face. 

Causation. — The  predisposing  causes  of  lupus  vulgaris  are  the  several 
cachexias  which  affect  the  poorly  fed  as  a  result  principally  of  being 
badly  housed  and  improperly  clothed  during  the  period  of  childhood 
and  early  adolescence.  The  immediate  cause  is  due  to  an  infection  of 
the  skin,  either  as  the  result  of  direct  contact  of  the  skin  with  tubercular 
matter  or  by  the  systemic  infection  of  the  integument  through  the  blood- 
or  lymph-channels. 

Symptoms. — The  appearance  of  small,  flattened,  slightly  elevated 
macules  upon  an  integumentary  surface  that  had  previously  been 
in  a  healthy  state  marks  the  beginning  of  lupus  vulgaris.  Later  these 
macules  become  nodular  or  papular  and  are  elevated  above  the  surface 
of  the  skin  from  which  they  spring.  The  nodules  may  be  clearly  made 
out  by  palpation  of  the  affected  area.  They  finally,  together  with  the 
areas  about  their  bases,  become  confluent,  the  whole  forming  a  "  patch" 
or  "  plaque."  The  color  of  such  a  patch  is  dull  red  or  purplish  and  the 
margins  have  clear-cut  lines  of  separation  from  the  healthy  integument. 
Sometimes  the  affected  area  is  more  or  less  marked  by  a  covering 
of  scales,  which  vary  in  appearance  from  a  whitish  to  a  yellowish 
brown. 

Lupus  vulgaris  usually  develops  slowly  and  persists  indefinitely. 
It  may  make  little  apparent  progress  for  a  long  period  of  years,  during 
all  of  which  time  little  or  'no  suffering  or  other  inconvenience  is  ex- 
perienced by  the  patient.  On  the  other  hand,  the  affected  tissues  may 
break  down  at  any  time,  ulceration  results,  and  dried  crusts  of  pus 
and  epithelial  debris  will  occupy  the  site  of  the  former  eruption.  An 
ulcer  thus  formed  sometimes  heals  in  one  part  while  it  extends  in  another, 
and  hence  it  is  not  uncommon  to  see  a  case  in  which  irregular  whitish 
cicatricial  scar  tissue  has  already  formed  in  the  wake  of  an  advancing 
ulceration.  The  nature  and  extent  of  the  ulcer  has  given  rise  to  different 
names  descriptive  of  the  ulcerative  stage  of  lupus  vulgaris.  Thus, 
when  it  advances  in  a  tortuous  course,  it  is  called  lupus  serpiginosus; 


CUTANEOUS  AFFECTIONS  OF  THE  EXTERNAL  EAR        117 

when  it  extends  deeply,  lupus  profundus;  when  it  spreads  superficially, 
lupus  superficialis,  etc. 

Lupus  vulgaris  involving  the  auricle  most  often  begins  on  the  lobule, 
which  later  becomes  swollen,  pendulous,  and  of  a  dark  red  or  purplish 
color.  When  ulceration  is  established  the  lobule  may  become  adherent 
to  the  face  or  neck,  the  entire  auricle  may  be  destroyed,  and  the  exter- 
nal auditory  meatus  may  be  closed  by  either  fungoid  granulations  or  a 
cicatrix. 

Diagnosis. — -The  earlier  stages  of  lupus  vulgaris  may  be  mistaken 
for  lupus  erythematosus.  In  the  latter  disease  the  process  is  superficial 
and  there  are  no  nodules,  ulcers,  or  thick  crusts  present.  In  lupus 
vulgaris,  as  has  just  been  pointed  out,  nodules  are  present  on  the  skin 
from  the  first,  and  ulceration  and  crust  formation  form  an  important 
part  of  the  later  behavior  of  the  disease. 

After  ulceration  has  been  established  lupus  vulgaris  may  be  mistaken 
for  either  epithelioma  or  syphilis.  Epithelioma  begins  at  a  later  period 
of  life  than  lupus,  its  course  is  more  rapid,  more  painful,  and  more 
exhaustive.  The  ulceration  of  lupus  may  be  multiple,  whereas  that 
of  carcinoma  is  single.  The  ulcer  of  lupus  may  heal  in  one  place  while 
it  progresses  in  another,  whereas  in  epithelioma  the  progress  of  the 
ulcerative  process  is  more  rapid  and  without  any  tendency  to  heal. 
The  edges  of  the  ulcers  of  lupus  are  soft,  while  those  of  carcinoma  are 
hard  and  elevated.  In  syphilis  the  history  of  the  ulcer  shows  it  to  be  of 
shorter  duration  than  lupus,  and  if  the  eyes,  nose,  and  throat  be  care- 
fully examined  other  evidences  of  previous  ulceration  or  inflammation 
in  these  localities  will  almost  certainly  be  discovered.  An  inspection 
of  the  general  integumentary  surfaces  of  the  body  may  also  furnish 
other  evidence  in  case  the  infection  was  of  a  specific  nature. 

Prognosis. — The  disease  may  persist  on  the  auricle  for  a  long  time 
without  further  harm  than  the  production  of  an  unsightly  cutaneous 
disorder;  or  it  may  completely  destroy  the  auricle  or  so  completely  change 
its  normal  structures  as  to  produce  a  hideous  deformity  of  the  appendage. 
When  the  external  auditory  meatus  is  involved,  atresia  of  the  canal  may 
result,  in  which  case  permanent  loss  of  hearing  on  the  affected  side  will 
ensue.  In  the  deeply  ulcerated  varieties  of  lupus,  systemic  infection 
and  death  is  the  usual  termination. 

Treatment. — Since  lupus  vulgaris  is  frequently  associated  with 
tuberculosis,  or  is  at  least  most  frequently  found  in  individuals  in  whom 
there  is  a  predisposition  to  this  disease,  all  those  remedies,  including 
personal  hygiene,  food,  exercise,  and  open  air,  are  indicated  which 
are  known  to  be  most  effective  in  combating  general  tuberculosis. 


n8 


THE   PRINCIPLES   AND    PRACTICE    OF    OTOLOGY 


FIG.  72. — PARTIAL  DESTRUCTION  OF  AURICLE 

BY  LUPUS  OF  LONG  DURATION. 
Whitish  scar  tissue  is  seen  extending  down- 
ward over  the  face,  result  of  healing  from  use 
of  a: -rays. 


The  local  treatment  consists  in  the  destruction  or  removal  of  the 
integumentary  infection.  Destruction  by  means  of  such  caustics  as 

nitric  acid,  lactic  acid,  or  trichloracetic 
acid,  or  by  means  of  caustic  alkalies, 
is  now  obsolete,  since  the  resulting  scar 
is  unduly  disfiguring,  and  since  these 
measures  are  by  no  means  certain  to 
secure  satisfactory  results.  If  the  dis- 
ease has  progressed  to  the  point  which 
makes  the  total  loss  of  the  auricle  in- 
evitable, the  whole  should  be  excised 
together  with  the  adjacent  structures 
which  are  most  involved.  While  the 
dermal  curet  is  a  popular  instrument 
for  the  removal  of  lupoid  areas  from 
other  parts  of  the  body,  it  is  not  suit- 
able for  their  removal  when  the  ear  is 
involved. 

The  best  results  in  the  treatment  of 
lupus  vulgaris  are  to-day  obtained  from 
the  use  of  the  Finsen  light,  photo- 
therapy, and  the  Arrays  (Fig.  72).  A  complete  description  of  the 
methods  of  employing  electrotherapy  in  the  cure  of  this  disease  is 
found  in  modern  works  on  this  subject,  and  to  these  the  reader  is 
referred. 

HERPES   ZOSTER 

But  few  cases  of  herpes  zoster  auris  have  been  reported.  Green 
and  Vail  have  each  studied  and  reported  cases  (Fig.  73).  Gruber  found 
5  cases  among  a  total  of  20,000,  representing  all  kinds  of  aural  affection. 
The  author  saw  in  1890  a  case  in  a  man  aged  forty,  who  was  the  victim 
of  a  severe  malarial  attack. 

Causation. — Most  writers  believe  that  a  neurotic  disturbance  is  the 
primary  cause,  and  Head  and  Campbell  found  in  21  post-mortem  ex- 
aminations that  inflammatory  and  degenerative  changes  existed  in  the 
ganglia  of  the  posterior  nerve-roots,  in  the  roots  themselves,  and  also 
in  the  peripheral  nerve-fibers  of  these  roots.  Reflex  irritation,  as  from 
the  ingestion  of  certain  foods,  has  been  assigned  as  a  cause  in  a  few 
cases.  Vail  states  that  the  affection  is  most  likely  an  acute  infectious 
disease,  and  this  view  is  supported  by  the  clinical  fact  that  herpes  zoster 
seldom  occurs  in  the  same  individual  a  second  time.  Exposure  to  a 
severe  cold,  damp  wind  is  an  active  predisposing  cause. 


CUTANEOUS  AFFECTIONS  OF  THE  EXTERNAL  EAR        119 

Symptoms. — Pain  of  a  neuralgic  character  and  sometimes  very 
severe  precedes  the  herpetic  eruption  one  or  more  days.  This  pain 
may  be  either  on  the  anterior  or  posterior  portion  of  the  auricle  or  upon 
the  adjacent  skin.  In  Vail's  case  it  was  severe  over  the  mastoid  process 
and  in  the  depths  of  the  external  auditory  meatus.  Gruber  has  ob- 
served the  herpes  in  the  auditory  canal  and  upon  the  drum  membrane, 
and  he  believes  that  the  disease  may  also  occur  in  the  middle  ear  itself. 
A  marked  degree  of  deafness  is  present  in  some  cases.  After  the  pain 
has  persisted  for  several  days  perhaps,  the  eruption  occurs.  The  vesi- 
cles, like  the  pain,  occur  over  the  course  and  distribution  of  the  sensory 


FIG.  73. — HERPES  ZOSTER  AURIS.     (Case  of  D.  T.  Vail.) 

nerves,  those  most  involved  being  the  great  auricular  branches  of  the 
cervical  plexus  and  the  auriculotemporal  branch  of  the  fifth.  Small 
red  patches  on  the  skin  precede  the  appearance  of  the  vesicles,  which 
may  be  thickly  set  or  even  confluent.  Since  the  deeper  layers  of  epithe- 
lium are  raised  with  the  blebs,  rupture  does  not  readily  take  place. 
At  first  the  contents  of  the  vesicles  are  serous,  later  milky,  finally  purulent, 
and  in  the  end  dry  into  a  scab  which  covers  the  site  of  a  permanent 
scar.  When  the  meatus  and  drum  membrane  are  involved  more  or 
less  deafness  and  tinnitis  aurium  are  present.  A  high  degree  of  fever 
sometimes  accompanies  the  early  period  of  the  disease. 

Treatment. — There  is  no  known  specific  medication,  and  therefore 


120  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

such  remedies  should  be  administered  inwardly  as  will  best  relieve  the 
pain  and  reduce  the  temperature.  In  the  worst  cases  morphin  or 
codein  may  be  given  hypodermically.  Phenacetin  or  acetanilid  in 
full  doses  are  proper  remedies  to  combat  the  high  temperature. 

Local  applications  are  of  little  value.  To  protect  the  vesicles  from 
the  irritating  effect  of  the  air  and  to  avoid  their  accidental  rupture  thick 
pads  of  cotton  should  be  placed  over  the  affected  region,  and  these 
should  be  held  in  place  by  a  roller  bandage. 


CHAPTER  IX 

ACUTE  CIRCUMSCRIBED  AND  ACUTE  DIFFUSE  INFLAM- 
MATION OF   THE   EXTERNAL   AUDITORY  MEATUS 

OTITIS   EXTERNA   CIRCUMSCRIPTA— FURUNCLE 

BOILS  occur  in  the  auditory  meatus  with  relatively  greater  frequency 
than  on  most  other  parts  of  the  body,  somewhat,  perhaps,  because  of 
the  exposed  situation  of  the  canal  itself,  but  principally,  no  doubt, 
because  of  the  frequency  with  which  suppurative  inflammation  occurs 
in  the  cavities  comprising  the  middle  ear  beyond. 

Causation. — Two  factors  may  be  considered  chief  among  the 
causative  agents  productive  of  this  disease,  namely,  traumatism  and 
subsequent  infection.  Kirchner  states  that  the  hair-follicles  of  the 
external  auditory  meatus  are  normally  inhabited  by  the  staphylococcus 
pyogenes  aureus  and  albus.  The  injury  to  the  part  may  be  so  slight 
that  the  patient  will  have  no  remembrance  of  its  occurrence,  but  it 
should  be  borne  in  mind  that  a  trivial  abrasion  of  the  skin  in  the  presence 
of  the  above  pathogenic  bacteria  is  ample  to  admit  the  germs,  and 
that  therefore  a  history  of  any  considerable  local  injury  preceding  the 
onset  of  the  circumscribed  external  otitis  is  not  necessary  to  the  estab- 
lishment of  the  fact  that  a  sufficient  abrasion  has  occurred.  Because 
of  the  insignificant  character  of  the  wound,  evidences  of  the  presence 
of  the  abrasion  are  not  always  visible  to  the  examiner,  even  upon  the 
most  careful  inspection  of  the  parts  involved. 

Picking  at  the  ear  to  relieve  itching  or  to  dislodge  accumulated 
wax  is  probably  the  most  frequent  cause  of  a  boil  in  this  location.  As 
is  stated  in  the  chapter  on  Impacted  Cerumen,  the  mere  presence  of 
the  hardened  wax  in  the  auditory  canal  for  a  long  time  will  often  erode 
the  underlying  parts,  which  are  then  open  to  the  entrance  of  infection. 
A  chronic  aural  discharge  acts  in  a  double  capacity  in  the  production 
of  furuncle:  first,  the  constant  bathing  of  the  canal  walls  with  the  irrita- 
ting pus  tends  to  soften  and  finally  abrade  the  skin;  second,  the  purulent 
material  is  usually  laden  with  pathogenic  material  ready  for  absorption 
by  any  exposed  surface  with  which  it  may  come  in  contact.  In  addition 
to  the  causes  just  stated,  certain  constitutional  disturbances,  like  anemia 

121 


122 


THE    PRINCIPLES   AND   PRACTICE    OF   OTOLOGY 


and  diabetes,  are  productive  of  boils  in  the  ear,  sometimes  coincidently 
with  their  occurrence  on  other  parts  of  the  body. 

Symptoms. — Usually  the  patient  first  discovers,  by  accidentally 
touching  the  ear,  that  a  rather  indefinite  sense  of  soreness  is  present 
in  that  locality.  This  rapidly  increases  until  within  twenty-four  or 
thirty-six  hours  it  has  become  a  pain  so  intense  and  continuous  as  to 
preclude  sleep,  and  although  apparently  lessened  during  the  day  it  is 
nevertheless  constantly  present  and  severe.  Owing  to  the  location  of  the 
boil  in  the  outer  portion  of  the  meatus  (Fig.  74),  and  therefore  upon  the 

tubular  portion  of  cartilage  which 
comprises  the  pinna,  any  move- 
ment of  the  external  ear  will 
result  in  very  severe  suffering. 
The  whole  auricle,  as  well  as 
the  soft  structures  adjoining  its 
attachment,  are  swollen  and  ede- 
matous  in  the  worst  cases.  When 
the  furuncle  is  situated  on  the 
posterior  wall  of  the  meatus  the 
amount  of  postauricular  swelling 
may  be  sufficient  to  cause  the 
auricle  to  stand  out  from  its  at- 
tachment to  the  extent  of  giving 
the  whole  head  a  lop-sided  ap- 
pearance (Fig.  181),  much  resem- 
bling that  sometimes  seen  during 
an  attack  of  acute  mastoiditis. 
If  the  situation  of  the  boil  is  on 

the  anterior  wall,  the  tragus  and    the   soft   tissues  anterior  to  it   are 
usually  swollen  and  exquisitely  tender  to  the  touch. 

In  the  worst  cases  there  is  some  rise  of  temperature,  but  rarely  will 
it  exceed  101°  F.  Loss  of  appetite,  general  malaise,  and  irritable 
disposition  are,  as  would  be  expected,  common  symptoms  in  a  disease 
attended  by  so  much  pain  and  loss  of  sleep. 

After  a  period  varying  from  two  to  several  days  from  the  onset,  a 
rupture  of  the  boil  takes  place  and  there  is  a  slight  discharge  of  bloody 
pus  from  the  auditory  meatus.  Following  this  an  immediate  relief 
from  the  pain  is  experienced,  the  patient  again  sleeps  well,  the  appetite 
returns,  the  temperature  drops  to  normal,  and  the  individual  believes 
himself  well  within  a  few  days.  In  many  instances,  however,  a  new 
infection  takes  place  in  a  short  time  and  the  patient  is  again  compelled 


Fio.  74. — FURUNCLE. 

Note  its  situation  on  the  cartilaginous  meatus  in 
the  outer  half  of  the  canal.  Compare  this  location 
with  the  sagging  of  the  inner  end  of  the  meatus  due 
to  mastoiditis  (see  Fig.  154). 


INFLAMMATION   OF   THE   EXTERNAL   AUDITORY   MEATUS  123 

to  undergo  a  repetition  of  his  former  suffering.  Indeed,  instances  are 
not  rare  in  which  one  crop  of  boils  follows  another  in  the  auditory 
meatus  with  such  little  intermission  that  the  patient  becomes  quite 
exhausted  before  the  disease  runs  its  natural  course  or  is  checked  by 
appropriate  treatment. 

The  hearing  is  not  seriously  impaired  except  in  cases  where,  because 
of  the  very  considerable  swelling  of  a  single  boil  or  of  the  combined 
tumefaction  of  a  group  of  boils,  the  lumen  of  the  canal  is  completely 
blocked.  Occlusion  of  the  canal  to  this  extent  may  also  produce  tinnitus 
aurium  and  vertigo. 

Diagnosis. — As  a  rule  the  diagnosis  of  this  disease  is  not  difficult, 
but  cases  are  occasionally  seen  which  are  exceptions  to  the  rule,  and 
these  are  deemed  of  sufficient  importance  to  merit  special  mention  under 
the  heading  of  differential  diagnosis;  first,  however,  the  diagnosis  of 
the  simple  case  will  be  discussed. 

Any  case  whose  symptoms  are  such  as  have  already  been  given 
would  be  suspected  of  having  furunculosis  of  the  external  auditory 
meatus.  Confirmation  of  this  belief  may  be  obtained  by  an  examination 
of  all  parts  of  the  auditory  canal  by  means  of  the  head- mirror  and 
reflected  light.  Since  the  boil  is  nearly  always  situated  in  the  outer  two- 
thirds  of  the  auditory  canal  it  is  better  in  all  examinations  where  this 
disease  is  suspected  not  to  use  the  speculum  as  a  first  step,  for  the  reason 
that  this  instrument  would  very  often  conceal  the  area  which  it  is  most 
necessary  to  examine.  The  auricle  is,  therefore,  retracted  in  the  usual 
way,  the  canal  is  illuminated,  and  its  walls  are  inspected  first  by  sight 
alone  and  later  by  means  of  the  cotton-tipped  applicator.  If  a  cir- 
cumscribed inflammation  is  present  it  will  be  found  necessary  to  handle 
the  auricle  very  gently  while  retracting  it,  and  to  touch  all  suspicious 
areas  lightly  with  the  probe,  since  otherwise  so  much  pain  will  be  pro- 
duced by  these  manipulations  that  few  patients  will  be  found  who 
possess  the  fortitude  to  tolerate  them.  In  its  incipiency  no  swelling  of 
the  canal  will  be  seen,  but  if  the  cotton-tipped  probe  be  used  and  all 
parts  of  the  outer  two-thirds  of  the  external  meatus  are  carefully  ex- 
amined for  tender  areas,  the  location  of  the  boil  may  thus  be  discovered 
in  the  very  beginning.  Later,  when  the  swelling  is  approaching  its 
height,  the  lumen  of  the  canal  will  be  more  or  less  occluded  and  will 
appear  somewhat  crescentic  in  shape. 

When  it  is  seen  by  the  above  method  of  examination  that  the  oc- 
clusion of  the  auditory  meatus  is  not  complete  and  that  the  tumefaction 
lies  deeply  in  the  canal,  the  aural  speculum  should  be  used  during  the 
subsequent  steps.  Even  when  moderate  swelling  of  the  canal  walls  is 


124  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

present  it  is  often  impossible  to  inspect  the  drum  membrane  when  the 
usual  short  speculum  is  employed.  In  these  cases,  therefore,  a  longer 
and  narrower  instrument,  such  as  is  shown  in  Fig.  99,  is  most  useful. 
Differential  Diagnosis. — Furunculosis  may  be  mistaken  for 
ether  acute  or  chronic  mastoiditis,  for  an  exostosis,  or  for  induration  or 
abscess  of  the  parotid  gland,  which  latter  occasionally  finds  an  exit 
through  the  slit  which  exists  in  the  cartilage  of  the  external  auditory 
meatus,  and  thence  discharges  through  the  canal  itself.  An  exostosis 
is  situated  in  the  bony  meatus  and  hence  lies  more  deeply  than  is  com- 
monly true  in  circumscribed  inflammation,  which  is  nearly  always  in  the 
cartilaginous  portion.  Moreover,  an  exostosis  is  painful  only  when 
the  skin  which  covers  it  is  ulcerated  and  inflamed — a  circumstance 
which  must  be  rare.  A  careful  examination  with  the  probe  should 
leave  no  room  for  question  as  to  the  real  nature  of  the  obstruction  within 
the  canal.  An  inflammatory  swelling  of  the  parotid  gland  is  usually 
a  sequel  to  some  general  infective  or  other  ailment,  and  therefore  the 
history  of  the  case,  taken  in  connection  with  the  evidence  obtained  by 
an  examination  of  the  ear  and  of  the  external  swelling,  should  be  sufficient 
to  clear  the  diagnosis.  It  is,  however,  with  the  differentiation  between 
a  boil  in  the  meatus  and  mastoiditis  that  the  physician  is  most  often 
concerned,  because  cases  are  not  infrequent  in  \vhich,  unless  one  pos- 
sesses considerable  knowledge  concerning  the  possible  behavior  of 
each  disease,  and  is  skilled  in  the  examination  of  the  deeper  parts  of 
the  ear,  mistakes  in  diagnosis  with  unpleasant  consequences  may  be 
made.  The  following  symptoms  and  conditions  found  in  each  ought 
to  enable  the  examiner  to  distinguish  the  one  from  the  other  ailment : 

FURUNCLE.  MASTOIDITIS. 

Pain. — Always  present  and  severe.  Pain. — Often  present,  not  always  severe. 

Aural  Discharge. — Infrequent  and  scanty.          Aural  Discharge.— Present  in  nearly  every 

case,  often  profuse. 

History. — Exceptionally  preceded  by  exan-     History. — Usually   preceded   by   exanthe- 
thematous   disease,    throat   affection,    or  mata,  la  grippe,  throat  affection,  and 

middle-ear  abscess.  nearly  always  by  middle-ear  abscess. 

Postauricular  Swelling. — May  be  present.         Postauricular  Swelling.— May  be  present. 

Tumefaction    -within    Auditory    Meatus. — Is  Tumefaction  within  Auditory  Meatus. — Is 
present  in  outer  two-thirds  of  the  canal,  present  at  fundus  of  canal,  and  only  in 

and  may  occur  on  anterior,  inferior,  or  one    situation,     namely,    the    postero- 

posterior  portion  of  canal  wall.  superior  canal  wall. 

Pain  on  Moving  the  Auricle. — Very  severe.       Pain  on  Moving  the  Auricle. — None. 

Pain  on  Pressure  over  Mastoid. — Absent  un-     Pain  on  Pressure  over  Mastoid. — Present 
less  the  auricle  is  moved  or  touched  dur-  at  tip,  over  site  of  mastoid  antrum,  and 

ing  the  manipulation.  sometimes  over  whole  mastoid  area  (see 

Fig-  ISO- 


INFLAMMATION   OF   THE    EXTERNAL    AUDITORY   MEATUS  125 

Treatment. — If  the  case  is  seen  in  its  incipiency,  efforts  should  at 
once  be  directed  to  the  abortion  of  the  inflammatory  swelling.  If  the 
individual  is  plethoric  or  if  the  local  congestion  is  very  active,  the  ab- 
straction of  blood  either  by  means  of  the  artificial  or  natural  leech  will 
not  only  give  temporary  relief,  but  will  often  be  the  means  of  arresting 
the  painful  affection.  The  blood  should  be  taken  from  a  point  nearest 
to  the  seat  of  the  inflammation,  and  hence  if  the  furuncle  is  located  on 
the  anterior  wall  of  the  meatus  the  depletion  should  be  performed  in 
front  of  the  tragus,  whereas  if  it  is  upon  the  posterior  wall  the  region 
of  the  mastoid  is  the  preferable  site  for  the  application  of  the  leeches. 
Since  leeching  is  employed  in  the  treatment  of  several  acute  aural  affec- 
tions, sufficient  detail  concerning  the  principles  of  its  use  and  the»  neces- 
sary technic  in  the  methods  of  its  application  can  be  most  appropriately 
given  here. 

Abstraction  of  blood  in  cases  of  local  congestion  and  inflammatory 
states  is  of  greatest  benefit  in  the  earliest  stages  of  the  disease;  but  its 
usefulness  as  an  abortive  or  curative  measure  diminishes  rapidly  as  the 
congestion  becomes  actively  inflammatory,  and  the  procedure  is  of  no 
value  whatever  when  the  suppurative  stage  has  been  reached.  Hence, 
the  abstraction  of  blood  can  be  recommended  only  in  the  earliest  stages 
of  an  inflammatory  aural  affection.  Natural  leeches  provide  a  well- 
known  and  efficient  method  of  local  depletion,  and  are  preferred  by  many 
otologists  to  the  newer  methods  in  vogue.  Some  knowledge  of  the 
behavior  of  the  natural  leech  is  essential  in  order  to  insure  its  efficient 
service.  It  is  perhaps  overparticular  concerning  the  kind  of  skin  on 
which  it  is  willing  to  operate.  Hence,  it  is  a  first  necessity  that  the  area 
to  be  leeched  must  be  thoroughly  scrubbed  and  cleansed,  for  the  purpose 
of  removing  the  smell  and  taste  of  any  poultice,  liniment,  or  other  medi- 
cation that  may  have  been  previously  applied.  The  last  cleansing  pre- 
vious to  applying  the  leech  should  be  made  with  pure  or  distilled 
water,  so  that  the  skin  may  be  absolutely  clean  and  free  from  all 
features  that  might  be  objectionable  to  the  animal. 

Before  attempting  its  application  the  auditory  canal  is  filled  with 
cotton  to  prevent  the  leech  from  crawling  into  this  passage,  a  thing  it  has 
often  been  known  to  do  when  the  precaution  above  mentioned  had  not 
been  taken.  When  all  necessary  preparation  has  been  made  the  leech 
is  placed  in  a  small  glass  cylinder,  like  a  test-tube,  by  which  means  it 
is  brought  into  contact  with  the  exact  spot  from  which  the  blood  is  to 
be  withdrawn.  If  it  does  not  readily  fasten  itself  to  the  skin,  the  latter 
may  be  pricked  with  a  needle  to  the  extent  of  causing  slight  bleeding, 
when  the  leech  will  more  energetically  seize  the  abraded  spot.  In  this 


126 


THE   PRINCIPLES   AND    PRACTICE    OF   OTOLOGY 


way  four  or  six  leeches,  as  may  be  indicated  by  the  severity  of  the  disease, 
can  be  applied,  and  all  should  be  left  on  until  they  fill  themselves  with 
blood  and  drop  off  of  their  own  accord. 

Because  of  the  difficulties  frequently  experienced  in  obtaining  and 
applying  natural  leeches,  and  the  great  amount  of  time  consumed  by 
this  method,  the  artificial  leech  has  come  into  very  general  use.  It  is 
more  certain,  more  efficient,  always  ready,  can  be  sterilized,  and,  indeed, 
possesses  every  advantage  over  its  older  rival.  Preceding  its  applica- 
tion the  area  to  which  it  is  to  be  applied  is  rendered  sterile,  after  which 
the  multiple  incisions  are  made  with  the  spring  lancet  (Fig.  75)  and 
the  suction-bulb  (Fig.  76)  is  at  once  applied.  The  small  amount  of 


FIG.  75. — BACON'S  SCARIFIER,  SHOWING 
LANCES  PROJECTING. 


FIG.  76. — CUPPING  GLASS  FOR  USE  IN  ABSTRACTING  BLOOD 
AFTER  SCARIFICATION  BY  MEANS  OF  THE  BACON  LEECH. 


pain  resulting  from  the  punctures,  which  are  made  by  the  little  lances 
of  the  instrument,  can  be  greatly  lessened  by  previously  placing  a  pad 
of  cotton  saturated  with  10  per  cent,  carbolic  acid  in  glycerin  over  the 
part  to  be  incised,  and  allowing  it  to  remain  ten  minutes  before  the 
incisions  are  made.  By  the  use  of  the  artificial  leech  2  or  more  ounces 
of  blood,  as  may  be  indicated,  can  be  easily  and  quickly  withdrawn. 

Should  hardened  ear-wax,  dried  pus,  or  other  foreign  material  be 
found  in  the  auditory  canal  during  the  formation  of  a  boil,  the  same 


INFLAMMATION   OF   THE    EXTERNAL   AUDITORY    MEATUS 


127 


should  be  completely  syringed  away.     After  the  canal  is  dried  the  pain 
can  be  lessened  in  many  cases  by  applying  a  neatly  shaped  cone  of  cotton, 
which  has  been  previously  saturated  with  ichthyol  ointment,  directly 
into  the  auditory  meatus  and  against  the  swelling.     This  should  be 
heated  before  it  is  inserted  and  should  be  left  in  place  for  twenty-four 
hours,  unless  the  pain  is  meanwhile  increased.     Solutions  of  menthol  also 
act  locally  as  an  anesthetic  and  often  prove  more  beneficial  in  this  respect 
than  ichthyol.     Solutions  of  morphin,  cocain,  and 
kindred  preparations  have  no  effect  on  the  pain 
when   applied  locally  and  are  unworthy  of  trial. 
The  continuous  application  of  the  hot-water  bottle 
to  the   ear  is   grateful  and   relieves  the  pain  in 
many  cases.     Incision  of  the  boil  constitutes  the 
best  treatment  in  the  majority  of  cases,  but  since 
the  procedure  is  exquisitely  painful  many  patients 
prefer  a  trial  of  the  milder  measures,  at  least  until 
the   continued   suffering   convinces   them   of  the 
wisdom  of  submitting  to  a  more  radical  measure. 
Incision,  when  performed  at  the  onset  of  a  boil, 
if  made  deeply  and  extensively  enough,  will  abort 
or  at  least  cut  short  the  subsequent  course  in  the 
majority  of    instances,  and  when  employed  thus 
early  takes  the  place  of  and  is  vastly  superior  in 
efficiency  to   the   local    abstraction  of  blood   by 
leeches.     Preparation  for  the  incision  is  made  by 
cleansing  the  canal  by  means  of  syringing  if  neces- 
sary, and  then  by  applying  a  cone  of  cotton  which 
has  been  saturated   with    10    per   cent,   carbolic 
acid    in    glycerin    directly    to    the    meatus    and 
against    the    swelling.     After    a    few    minutes  it 
will  be  found  that  the  affected  area  is  somewhat 
anesthetized.     The  amount  of  pain  produced  in 
lancing  a  furuncle  is  dependent  very  greatly  upon  the  method  of  making 
the  incision.     The  furuncle  knife  (Fig.  77  or  78)  should  be  in  perfect 
order,  the  patient's  head  should  be  firmly  supported  between  the  two 
hands  of  an  assistant,  the  auricle  should  be  retracted,  and  the  field  of 
operation  should  be  well  illuminated.     If  the  patient  be  a  child  or  a 
nervous  adult,  the  hands  of  the  patient  must  be  held  by  an  assistant. 
The  knife  is  inserted  into  the  meatus  to  a  point  beyond  the  tumefaction, 
and  is  then  turned  so  that  the  cutting  edge  is  perpendicular  to  the  latter. 
By  firm  pressure  upon  the  handle  of  the  knife,  the  point  is  driven  as 


FIGS.  77,  78. — FURUNCLE 
KNIVES. 


128  THE    PRINCIPLES    AND   PRACTICE   OF   OTOLOGY 

deeply  as  the  bone  or  periosteum,  and  at  this  depth  the  blade  is  pulled 
outwardly  through  the  whole  length  of  the  furuncle,  thus  draining  not 
only  the  accumulation  of  pus,  but  also  the  congested  tissues  that  sur- 
round the  pyogenic  space. 

The  after-treatment  consists  in  antiseptic  cleansing  and  the  applica- 
tion of  emollient  medicaments  to  the  inflamed  area.  The  cotton  cone, 
saturated  with  ichthyol  ointment,  when  applied  hot  into  the  external 
meatus  proves  valuable  in  allaying  subsequent  pain,  in  reducing  the 
tumefaction,  and  from  its  action  as  a  local  antiseptic. 

The  general  health  of  the  patient  sometimes  needs  attention.  De- 
rangements of  the  digestive  system  are  particularly  active  as  factors 
in  keeping  the  local  inflammation  alive.  When  this  is  the  case  the 
regulation  of  the  diet  and  mode  of  life,  in  connection  with  the  adminis- 
tration of  salines,  will  be  found  especially  helpful.  Anemia,  when 
present,  is  an  indication  for  the  administration  of  iron.  The  tendency 
toward  a  recurrence  of  the  furuncle  and  ultimate  chronicity  of  the 
disease  may  be  caused  by  diabetes,  and  an  examination  of  the  urine  is 
therefore  imperative.  Should  sugar  be  found,  diabetic  diet  and  general 
treatment  for  that  disease  should  be  at  once  instituted. 

DIFFUSE   INFLAMMATION    OF   THE   EXTERNAL   AUDITORY   MEA- 
TUS—OTITIS   EXTERNA    DIFFUSA 

As  a  result  of  an  injury  to  the  canal  or  of  the  previous  existence 
of  some  other  disease  in  this  locality,  the  resulting  inflammation  some- 
times involves  the  whole  channel  instead  of  becoming  localized,  as  in  the 
preceding  ailment. 

No  satisfactory  explanation  can  be  offered  as  to  why  the  one  disease 
is  more  extensive  than  the  other,  except  in  those  cases  where  the  initial 
irritation  of  the  canal  is  widely  distributed  in  one  and  not  in  the  other. 

Causation. — The  cause  of  the  affection  can  usually  be  traced 
to  the  entrance  into  the  canal  of  irritating  fluids  or  of  foreign  bodies 
with  sharp  edges  which  deeply  lacerate  the  integument  of  the  meatus, 
or  which  otherwise  involve  the  integrity  of  the  auditory  canal  to  some 
considerable  extent.  The  foreign  body  may  have  been  smooth  and 
may  have  entered  the  canal  without  any  injury  whatever  to  the  parts, 
but  the  subsequent  unskilful  efforts  to  remove  it  have  caused  the  injury 
which  has  resulted  in  the  diffuse  inflammation.  Likewise  the  unskilful 
use  of  instruments  in  the  meatus  for  any  purpose  may  cause  an  injury 
which  will  result  in  the  disease  under  consideration. 

An  eczema  of  the  canal  often  persists  a  long  time  with  no  more 
discomfort  than  itching,  but  upon  exposure  to  severe  cold  or  as  the 


INFLAMMATION   OF   THE    EXTERNAL   AUDITORY  MEATUS  1 29 

result  of  rudely  scratching  the  parts  to  relieve  the  itching,  an  otitis 
externa  diffusa  may  be  started.  Irritating  discharges  from  the  middle 
ear  have  been  known  to  set  up  the  disease  without  any  other  assignable 
cause  being  present.  Infection  at  the  point  of  injury  by  the  staphylo- 
coccus  pyogenes  aureus  or  albus  is  no  doubt  an  essential  in  all  instances 
to  the  establishment  of  the  disease. 

Symptoms. — The  pain  resulting  from  the  swelling  and  tension 
within  the  canal  varies  from  that  which  amounts  to  only  an  uncom- 
fortable soreness  to  that  which  is  so  severe  as  to  be  almost  unbearable. 
As  is  true  in  most  affections  of  the  ear,  the  suffering  is  worse  at  night. 
The  hearing  is  not  greatly  impaired  except  when  the  inflammation  is 
of  such  severity  that  the  auditory  meatus  is  blocked  or  unless  the  drum 
membrane  is  involved — thickened  or  perforated  and  covered  with  an 
exudate. 

In  addition  to  the  hyperemia  and  swelling  of  the  canal  walls,  ecchy- 
moses  sometimes  occur,  and  in  thirty-six  or  forty-eight  hours  a  dis- 
charge which  is  at  first  serous  and  afterward  purulent  will  be  observed. 
This  discharge  finally  dries  into  crusts  which  encase  the  meatal  walls, 
and  these  when  removed  often  represent  partial  or  complete  casts  of 
the  canal.  Since  the  dermoid  layer  of  the  drum  membrane  is  involved 
in  the  inflammatory  process,  and  is  later  cast  off  along  with  the  epider- 
mal layers  of  the  outer  canal,  an  examination  of  the  canal  and  fundus 
by  means  of  reflected  light  shows  obliteration  of  all  landmarks  of  the 
drum  membrane.  After  this  exfoliated  portion  of  the  drum  membrane 
is  shed  or  has  been  removed  the  underlying  structures  look  moist  and 
angry,  the  junction  of  the  tympanic  membrane  with  the  canal  walls 
cannot  be  made  out,  and  in  severe  cases  the  drum  membrane  is  found 
to  be  perforated,  with  a  discharge  from  the  middle  ear. 

The  discharge  from  the  meatus  is  often  corrosive  to  the  parts  with 
which  it  comes  in  contact,  and  hence  the  auricle  is  not  infrequently 
eroded  and  swollen  as  a  result.  There  may  also  be  present  an  enlarge- 
ment and  tenderness  of  the  lymphatic  chain  of  glands  in  the  neck, 
as  a  result  of  the  absorption  of  septic  material  from  the  external 
meatus. 

Differential  Diagnosis. — The  affection  may  be  mistaken  for  a 
boil  in  the  canal  or  for  otitis  media.  As  previously  stated  a  boil  causes 
swelling  from  one  side  of  the  canal  only,  and  hence  on  examination  the 
lumen  of  the  meatus  is  crescentic  during  furunculosis,  whereas  in  the 
disease  under  consideration  the  lumen  is  about  equally  encroached  upon 
from  all  sides  and,  therefore,  the  opening  of  any  channel  yet  remaining 
is  in  the  center  line  of  the  meatus  and  continues  to  be  more  or  less  cir- 

9 


130  THE    PRINCIPLES   AND    PRACTICE    OF   OTOLOGY 

cular  in  outline.  The  history  of  the  onset  and  the  physical  examination 
should  serve  to  distinguish  a  suppurative  otitis  media  from  an  acute 
diffuse  external  otitis. 

Prognosis. — In  the  milder  cases  and  those  of  uncomplicated  trau- 
matic origin  the  outcome  is  generally  good.  Cases  of  this  character 
usually  pass  through  the  stages  of  exudation,  exfoliation,  and  crusting, 
and  end  in  complete  cure  in  from  two  to  four  weeks.  In  ill-nourished 
or  tubercular  subjects  the  disease  may  persist  much  longer  or  may 
even  become  chronic.  Those  cases  in  which  the  inflammation  of  the 
canal  is  due  to  a  previously  existing  eczema,  or  perhaps  those  in  which 
both  an  eczema  and  a  purulent  discharge  from  the  middle  ear  have 
been  present,  the  prognosis  is  less  favorable,  the  disease  may  require 
a  much  greater  time  for  its  cure,  and  is  much  more  likely  to  become 
chronic.  Should  the  active  inflammation  persist  in  the  narrow  or, 
perhaps,  occluded  auditory  canal  for  any  considerable  time  the  result 
may  be  an  adhesion  and  permanent  narrowing  of  the  lumen  of  the 
canal  at  some  point;  or  interstitial  infiltration  and  thickening  of  both 
the  osseous  and  soft  parts  of  the  canal  may  take  place  to  the  extent 
that  the  external  auditory  meatus  is  ultimately  occluded  throughout  its 
whole  length.  Stricture  of  the  meatus  from  any  cause  may  do  no  further 
harm  than  to  seriously  impair  the  hearing,  but  in  case  suppuration 
previously  existed  in  the  tympanic  cavity  or  was  brought  on  by  the 
external  inflammation,  serious  danger  to  the  life  of  the  individual  may 
result  from  the  hindrance  thus  offered  to  the  drainage,  and  the  conse- 
quent liability  of  extension  of  the  suppuration  to  the  cranial  contents. 

Treatment. — When  the  case  is  seen  early  the  indications  for  treat- 
ment are  to  relieve  the  pain  and,  if  possible,  to  abort  or  check  the  in- 
flammatory progress.  The  same  measures  that  were  recommended 
in  the  incipiency  of  the  circumscribed  variety  of  external  otitis  are 
equally  valuable  in  the  diffuse  variety.  These  include  the  adminis- 
tration of  salines,  the  local  abstraction  of  blood,  the  application  of 
anodyne  substances  locally,  and  deep  incision  of  the  tumefied  part 
(see  p.  125). 

When  the  secretion  appears  it  should  be  frequently  removed  by 
syringing.  When  this  secretion  is  highly  irritating  its  reaction  should 
be  tested,  and  the  lotion  which  is  used  for  cleansing  should  be  rendered 
slightly  alkaline  or  acid,  as  may  be  necessary  to  neutralize  the  discharge. 
After  syringing,  thorough  drying  of  the  canal  is  essential,  following 
which  the  causation,  as  well  as  the  exact  nature  of  the  present  wounded 
or  inflamed  canal,  must  be  carefully  considered  in  order  to  determine 
the  most  appropriate  medicament  to  be  applied.  Many  of  the  moist 


INFLAMMATION   OF   THE    EXTERNAL    AUDITORY   MEATUS  131 

cases  are  most  efficiently  treated  by  the  application  to  the  canal  of  a 
drying  powder, 

R .  Pulv.  amyli,  jiij; 

Zinci  oxidi,  3j; 

Columnae,  £ss. — M. 
D  usting-powder . 

after  first  syringing  away  the  discharge  and  subsequently  drying  the 
inflamed  area.  Solutions  of  nitrate  of  silver  are  highly  beneficial  in 
cases  where  the  infiltration  is  great,  but  the  secretion  scanty.  Such  a 
solution  should  not  be  stronger  than  gr.  xx  to  3  j  to  begin  with,  but  may 
be  increased  to  four  times  this  strength  if  well  tolerated.  Should  silver 
nitrate  prove  irritating  or  ineffectual,  the  cotton  plug  saturated  with  a 
compound  mercury  ointment  may  be  inserted,  and  is  often  most  bene- 
ficial : 

Ii .  Hydrarg.  ammon., 

Hydrarg.  oxidi,  ad  gr.  ij; 
Adipes  benzoate,  3^J> 

Oleum  olivae,  3J- — M. 

Constitutional  disturbances  of  whatever  nature,  especially  those  per- 
taining to  the  digestive  tract,  should  be  corrected.  Lithemia  is  par- 
ticularly influential  as  a  factor  in  the  continuance  of  an  inflammatory 
state  that  originates  from  an  eczema,  and  hence  both  an  antilithemic 
diet  and  antilithemic  drugs  are  frequently  indicated. 

When  septa  or  stenosis  of  the  auditory  canal  results  from  the  violence 
of  the  inflammation  or  as  a  sequel  to  its  long  continuance,  the  deformed 
canal  may  require  mechanical  or  surgical  treatment  to  restore  the 
hearing  or  to  prevent  the  retention  of  pus  or  other  secretion  in  the 
cavities  of  the  middle  ear  should  suppuration  be  already  present  there 
or  should  it  subsequently  take  place.  Membranous  septa  that  are  found 
in  the  canal  may  be  cut  away,  and  in  order  to  prevent  their  re-formation 
the  opening  should  be  filled  with  a  properly  shaped  plug  of  dental  wax; 
or  a  sponge  tent  may  be  used  for  this  purpose,  but  must  be  frequently 
replaced  until  healing  has  taken  place.  This,  like  other  scar  tissue, 
has  a  tendency  to  re-form  again,  and  much  trouble  is  sometimes  ex- 
perienced in  keeping  the  canal  patent  even  after  the  most  thorough 
removal  of  the  obstruction.  If  the  canal  is  closed  on  one  side  of  the' 
head  only,  if  the  hearing  is  good  in  the  opposite  ear,  and  if  there  is  no 
suppurative  process  going  on  in  the  middle  ear  of  the  affected  side,  it  is 
best  not  to  interfere  with  the  obstruction  in  the  meatus.  If,  however, 
the  hearing  in  the  opposite  ear  is  greatly  impaired  or  completely  lost, 
and  the  tuning-fork  tests  show  the  labyrinth  of  the  ear  on  the  obstructed 


132  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

side  to  be  normal,  the  auricle  should  be  detached  almost  exactly  as 
advised  in  the  performance  of  the  first  step  of  the  radical  mastoid 
operation,  and  a  groove  should  be  chiseled  from  the  mastoid  cortex 
sufficiently  wide  and  deep  to  furnish  an  ample  opening  for  a  new 
auditory  meatus  after  the  posterior  meatal  integument  is  turned  back- 
ward into  its  new  position. 

In  case  a  chronic  suppuration  exists  in  the  middle  ear  of  an  individual 
who  has  complete  or  nearly  complete  cicatricial  or  other  obstruction 
in  the  auditory  canal,  the  radical  mastoid  operation  is  indicated  and 
should  be  performed  without  unnecessary  delay  (see  Chapter  XXX). 


CHAPTER  X 

CROUPOUS  AND  DIPHTHERITIC  INFLAMMATION   OF 
THE   EXTERNAL   AUDITORY   MEATUS 

CROUPOUS  INFLAMMATION 

THIS  name  has  been  given  to  that  form  of  diffuse  inflammation  of 
the  auditory  meatus  in  which  there  is  a  deposit  of  a  membranous  exudate 
over  more  or  less  of  the  integumentary  lining  of  the  external  auditory 
canal.  This  false  membrane  is  at  first  pearly  white  and  filmy  in 
appearance,  but  later  may  become  thick,  opaque,  and  of  a  grayish  or 
dirty  color.  It  lies  accurately  in  contact  with  the  underlying  skin, 
but  is  not  firmly  attached  to  it,  and  hence  the  examiner  will  be  able 
to  lift  up  the  presenting  edges  with  a  spatula  or  probe,  or  to  remove  the 
entire  cast  from  the  meatus  by  means  of  a  dressing  forceps  or  by  syring- 
ing the  canal. 

According  to  Politzer,  the  membrane  is  confined  entirely  to  the 
osseous  portion  of  the  auditory  canal  and  to  the  dermoid  layer  of  the 
drum  membrane.  The  membranous  deposit  is  composed  of  coagulated 
fibrin  and  white  blood-corpuscles,  from  which  have  also  been  isolated 
the  staphylococcus  pyocyaneus  and  the  streptococcus  pyogenes. 

The  cause  of  this  affection  is  most  probably  the  presence  in  the 
auditory  meatus  of  these  two  varieties  of  pathogenic  bacteria. 

Pain  accompanies  the  onset  of  the  exudate,  persists  during  its  pres- 
ence, and  subsides  soon  after  it  is  exfoliated.  Recurrence  is  frequent, 
but  under  proper  treatment  the  entire  trouble  promptly  subsides  without 
any  impairment  of  hearing  or  other  injury  to  the  auditory  apparatus. 

The  treatment  of  the  affection  is  simple  and  consists  in  the  removal 
by  antiseptic  syringing  of  all  retained  pus  together  with  the  membrane 
itself.  If  syringing  is  not  effective  in  the  removal  of  the  membrane  the 
small  aural  dressing  forceps  may  be  employed  for  this  purpose,  but  the 
latter  must,  of  course,  be  guided  by  the  eye  and  a  good  reflected  light. 
When  the  affected  parts  are  clean  and  free  from  the  membrane  and 
have  been  dried  by  the  introduction  of  cotton  cylinders  into  the  external 
auditory  meatus,  the  dressing  is  completed  by  dusting  the  meatus  lightly 
with  boric  acid  powder. 

133 


134  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

DIPHTHERITIC  INFLAMMATION 

This  is  a  more  common  and  a  much  more  serious  disease  than  the 
preceding,  and  may  be  either  primary  or  secondary  to  a  similar  diph- 
theritic deposit  in  the  fauces,  nasopharynx,  nose,  or  middle  ear  of  the 
same  individual.  It  is  scarcely  probable  that  a  diphtheritic  membrane 
is  ever  primarily  produced  in  the  auditory  meatus  unless  there  already 
existed  abrasions  or  excoriations  of  the  skin  in  this  locality.  Hence, 
the  disease  is  found  primarily  only  as  a  complication  of  irritating  aural 
discharges,  after  the  skin  has  been  denuded  of  its  protective  epithelium. 

In  diphtheritic  inflammation  of  the  external  auditory  meatus  when 
occurring  as  a  complication  of  nasopharyngeal  diphtheria,  the  specific 
bacillus  finds  its  way  into  the  middle  ear  through  the  Eustachian  tube, 
throughout  which  tract  the  characteristic  exudate  takes  place.  As  a 
combined  result  of  the  pressure  due  to  the  inflammatory  swelling  of 
the  tympanic  mucous  membrane  and  of  the  inflammatory  exudate 
which  speedily  occurs,  rupture  of  the  membrana  tympani  takes  place 
and  an  irritating  discharge  flows  through  the  auditory  canal,  the 
integumentary  lining  of  which  becomes  at  once  excoriated  and  infected. 

At  first  white  and  thin  in  appearance,  the  membrane  rapidly  spreads 
and  thickens  until  it  may  involve  a  part  of  the  auricle  and  occlude 
the  meatus  by  its  own  thickness  and  the  increased  swelling  of  the  under- 
lying tissues.  The  lymphatics  behind  the  ear  become  tender  and 
swollen,  and,  together  with  the  infection  of  the  glands  of  the  neck  that 
has  previously  taken  place  from  the  faucial  diphtheria,  produces  a  tume- 
faction of  the  neck  of  considerable  extent.  Unlike  the  membranous  exu- 
date which  takes  place  in  the  auditory  canal  in  the  croupous  variety,  that 
which  occurs  in  diphtheria  is  closely  adherent  to  the  underlying  skin 
and  cannot  be  syringed  away  or  removed  without  injury  to  the  skin 
itself.  Should  some  part  of  it  be  forcibly  pulled  away,  the  surface  to 
which  it  was  attached  is  left  raw  and  bleeding,  and  another  membrane 
is  immediately  formed  to  cover  the  denuded  spot.  In  addition  to  this 
important  difference  in  the  behavior  of  the  two  classes  of  exudate,  the 
fact  that  in  the  diphtheritic  variety  the  disease  is  usually  secondary 
to  a  throat  attack  should  lead  to  an  easy  differential  diagnosis.  If, 
however,  any  doubt  should  exist  concerning  this  point,  a  bacteriologic 
examination  should  be  made  to  settle  it. 

The  treatment  should  be  directed  to  the  cure  of  the  general  diph- 
theria, of  which  that  involving  the  ear  forms  only  a  part.  If  antitoxin 
has  not  been  administered  before  the  process  is  recognized  in  the  ear, 
injection  of  this  remedy  should  be  made  at  once,  and  repeated  one  or 


CROUPOUS   AND    DIPHTHERITIC    INFLAMMATION  135 

more  times  daily  as  may  be  indicated  to  limit  the  further  spread  of  the 
membrane,  to  secure  its  exfoliation,  and  to  prevent  its  recurrence. 

The  external  meatus  is  treated  by  antiseptic  syringing  and  by  the 
instillation  of  solutions  to  dissolve  and  loosen  the  membrane  and  to 
soothe  the  inflamed  canal.  When  the  disease  is  primary,  Gottstein 
advises  filling  the  auditory  canal  with  lime-water,  which  he  states  will 
favor  the  separation  of  the  membrane.  Efforts  to  remove  the  diphther- 
itic deposit  by  means  of  instruments  before  it  is  loosened  by  remedial 
or  natural  processes  are  always  harmful,  and  result  in  injury  to  the  under- 
lying tissues;  such  efforts  are  also  productive  of  great  pain,  and  even 
if  successful  are  not  of  benefit,  for  the  reason  that  the  membranes  are 
re-formed  at  once,  and  usually  to  a  greater  extent  than  before  their 
removal. 


CHAPTER  XI 

PARASITIC  INFLAMMATION  OF  THE  EXTERNAL  AUDI- 
TORY CANAL— FUNGOID  OTITIS  EXTERNA.— OTO- 
MYCOSIS 

SEVERAL  varieties  of  vegetable  parasites  have  been  discovered  in  the 
external  auditory  canal,  each  of  which  has  been  exhaustively  studied 
and  described  by  a  number  of  observers. 

Causation. — While  the  conditions  that  lead  to  the  development  of 
this  disease  cannot  be  stated  in  every  case  of  otomycosis,  several  factors 
will  usually  be  found  present  in  the  meatus  which  are  contributory  to 
the  origin  of  the  growth.  In  the  first  place,  the  mycelium,  like  all  other 
types  of  plant  life,  cannot  live  on  an  absolutely  dry  skin,  and  hence  one 
essential  for  its  existence  in  the  auditory  meatus  is  that  there  be  present 
a  moisture  or  discharge  of  some  kind  upon  which  the  growth  may 
subsist.  A  very  profuse  purulent  discharge,  however,  seems  to  be  pro- 
hibitive of  the  development  of  the  fungus,  owing  perhaps  to  the  fact 
that  the  spores  are  washed  away  before  they  can  attach  themselves; 
or  that  they  are  quickly  drowned  in  the  excess  of  fluid  present.  Bezold, 
Dench,  and  others  state  that  the  use  of  oils  in  the  ear  for  any  purpose 
predisposes  the  individual  to  the  development  of  the  fungus,  but  in  view 
of  the  frequency  with  which  patients  suffering  from  aural  diseases 
apply  fatty  mixtures  to  the  auditory  canal  it  would  seem  that  fungi 
should  be  seen  oftener  in  this  situation  than  is  the  case  at  present  if  oils 
were  a  potent  factor  in  the  causation.  The  deeper  portions  of  the 
auditory  canal  are  most  often  involved.  Adults  are  affected  more 
frequently  than  children  and  males  oftener  than  females.  The  disease 
is  most  common  among  those  living  in  crowded  tenements,  particularly 
in  damp  places.  Pain  of  varying  degree,  seldom  intense,  is  usually 
present,  but  cases  are  sometimes  seen  in  which  no  complaint  of  any 
kind  is  made  by  the  patient. 

Diagnosis. — The  character  of  the  disease  may  be  suspected  from 
the  symptoms,  but  can  only  be  definitely  determined  by  a  physical 
examination  of  the  auditory  canal  and  drum  membrane,  and  if  then  in 
any  doubt,  by  a  microscopic  examination  of  any  suspected  foreign 
material  that  may  be  removed  from  the  meatus.  If  the  parasite  is  of  the 

136 


PARASITIC    INFLAMMATION   OF   THE   EXTERNAL   AUDITORY   CANAL     137 

variety  known  as  aspergillus  niger,  the  walls  and  fundus  of  the  meatus 
will  appear  blackened  as  though  coated  with  a  fine  coal-dust,  whereas 
if  the  aspergillus  flaveus  is  present  it  presents,  under  illumination,  a 
yellowish  aspect  and  the  canai  looks  somewhat  as  if  it  had  been  dusted 
with  iodoform  or  the  pollen  of  certain  plants.  Under  the  microscope 
the  aspergillus  niger,  the  fungus  most  frequently  seen,  appears  as  a 
mass  consisting  of  numerous  long  transparent  fibers  which  ultimately 
divide  into  two  branches  and  end  in  a  head  containing  the  reproductive 
parts  of  the  plant  (Fig.  79).  The  fibers  comprising  the  stems  of  the 


FIG.  79. — ASPERGILLUS  NIGER. 
a,  Mycelium  fiber ;  b,  spores ;  c,  sporangium ;  d,  receptaculum ;  e,  sterigmata.     (Holmes.) 

growth  lie  in  close  contact  with  the  superficial  epithelium  of  the  skin, 
interlace  each  other,  and  embrace  in  their  loops  the  intervening  epithe- 
lial cells  to  such  an  extent  that  when  the  growth  is  pulled  or  washed 
away  from  its  skin  attachment  the  underlying  surface  is  left  somewhat 
raw  and  bleeding. 

Eczematous  or  other  inflammatory  diseases  of  the  canal  may  cause 
an  exfoliation  of  the  epidermal  layers  which  can  be  readily  mistaken 
for  a  fungoid  accumulation,  but  the  microscope,  if  used  for  the  examina- 
tion of  the  exfoliated  structure,  will  leave  no  doubt  concerning  its 
nature. 

Treatment. — The  diagnosis  having  once  been  made  with  certainty, 
proper  and  efficient  treatment  becomes  an  easy  matter.  As  a  preliminary 
to  the  measures  which  are  intended  to  kill  the  growth,  as  much  of  it  as ' 
possible,  together  with  any  hardened  wax  or  other  foreign  material 
that  may  be  present  in  the  canal,  is  first  syringed  away  with  an  anti- 
septic fluid  or  is  withdrawn  from  the  canal  by  means  of  an  aural 
forceps.  Warm  rectified  spirits  or  alcohol-boric  acid  solution  is  then 


138  THE   PRINCIPLES    AND   PRACTICE   OF   OTOLOGY 

instilled  into  the  canal  and  allowed  to  remain  for  ten  minutes.1  This 
is  repeated  one  or  more  times  daily  for  a  few  days,  at  the  end  of  which 
time,  if  the  fungus  shows  no  sign  of  returning,  the  patient  may  be  dis- 
missed with  instructions  to  repeat  the  instillations  at  home  once  or 
twice  a  week.  Should  either  of  the  above  solutions  be  painful  to  the 
ear  the  same  may  be  diluted  with  distilled  water,  after  which  the  former 
strength  is  again  gradually  restored  as  toleration  is  established.  Some- 
times the  alcohol-boric  acid  solution  fails  to  act  satisfactorily,  and  then 
mercury  bichlorid  may  be  substituted  for  the  boric  acid  and  be  added 
to  the  alcohol  in  the  proportion  of  i :  800. 

After  the  cure  of  the  disease  by  the  above  means,  recurrence  is  apt 
to  take  place  unless  any  disease  which  may  be  present  in  the  auditory 
meatus  or  middle  ear  is  at  the  same  time  cured  and  the  meatus  restored 
to  a  normal  condition.  Hence,  any  discharge  from  the  tympanic  cavity 
or  any  inflammatory  thickening  of  the  walls  of  the  external  auditory 
canal  should  receive  treatment  appropriate  to  the  existing  ailment. 

1  The  alcohol-boric  acid  solution  here  referred  to  is  prepared  by  adding  gr.  xx  boracic 
acid  to  J  commercial  alcohol. 


CHAPTER  XII 

FOREIGN  BODIES  IN  THE  EXTERNAL  AUDITORY 

MEATUS 

FOREIGN  bodies  in  the  auditory  canal  are,  in  the  large  majority  of 
instances,  lodged  there  by  the  individual  himself.  Children  at  play 
with  objects  of  any  kind  seem  to  possess  a  natural  desire  to  introduce 
the  same,  when  small  enough  to  permit  it,  into  the  mouth,  nose,  or  ear. 
More  rarely  the  lodgment  of  a  foreign  body  in  the  ear  results  accidentally, 
as  when  a  person  picks  at  the  canal  with  a  toothpick,  match,  or  other 
like  implement  for  the  purpose  of  removing  hardened  wax,  or  to  scratch 
the  meatus  during  the  torturing  itch  of  an  eczema  in  this  locality,  and  a 
portion  of  the  object  is  broken  off  at  a  depth  beyond  the  ability  of  the 
patient  to  recover.  Portions  and  even  the  whole  of  small  hairpins  and 
parts  of  toothpicks  and  matches  have  in  this  way  been  lost  in  the  canal. 
Various  objects  may  enter  the  ear  by  being  in  some  way  hurled  from  a 
distance.  Thus,  seeds  may  fly  into  the  farmer's  ear  during  the  process 
of  threshing  grain;  chips  of  stone  or  scales  of  iron  or  other  substance 
with  which  various  artisans  work  may  likewise  accidentally  enter  the  ear, 
being  cast  off  from  the  chisel  or  other  implement  in  use.  Of  a  more 
violent  and  rarer  origin  may  be  mentioned  gun-wads  or  even  bullets 
that  have  been  shot  into  and  lodged  in  the  canal,  or  possibly  imbeded 
in  the  deeper  structures  of  the  ear  beyond. 

Bugs  and  insects  are  frequently  met  with  in  the  auditory  meatus, 
among  which  bedbugs,  ticks,  roaches,  and  the  like  are  most  often  ob- 
served. In  some  localities,  usually  in  warm  countries,  where  outdoor 
life  is  almost  perpetual,  insects  sometimes  enter  discharging  ears  and 
there  deposit  their  eggs,  from  which  larvae  are  subsequently  hatched 
in  numbers  sufficiently  large  to  fill  the  canal.  Calhoun,  of  Atlanta, 
reported  the  case  of  an  ear  in  which  he  found  several  live  maggots, 
which  had  presumably  crawled  into  the  ear  of  the  patient  from  the 
horse  stall  in  which  he  had  been  sleeping. 

Otoliths  sometimes  form  in  the  external  auditory  meatus.  Godwin1 
reports  the  extraction  of  such  a  formation  from  the  meatus  of  a  woman 
aged  thirty.  The  concretion  consisted  of  a  mixture  of  calcium  phosphate, 

1  Brit.  Medical  Journal,  March  5,  1905. 

139 


I4O  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

cerumen,  and  epithelium.  The  author  removed  an  otolith  from  the 
external  meatus  of  a  negro,  in  1894,  which  was  large  enough  to  fill  the 
entire  canal  and  to  greatly  impair  the  hearing  on  that  side.  It  was 
molded  exactly  to  the  shape  of  the  meatus  and  greatly  resembled  the 
petrified  twig  of  a  tree. 

Symptoms. — The  symptoms  of  a  foreign  body  in  the  canal  may 
vary  from  those  so  trivial  that  the  individual  is  entirely  ignorant  of  its 
presence  to  those  in  which  there  may  be  great  disturbance  or  even  total 
loss  of  function,  severe  pain,  and  marked  general  disturbance. 

It  is  not  an  uncommon  occurrence  to  remove  some  small  foreign 
body,  as  a  bead,  pebble,  or  like  substance  from  an  ear  at  the  first  exami- 
nation for  another  ailment,  when  the  patient  will  deny  all  knowledge 
of  its  presence,  it  having  given  rise  at  no  time  to  any  inconvenience. 
If  the  object  is  large  enough  to  fill  the  canal  and  block  the  passage  of 
sound-waves,  the  hearing  is  impaired  and  tinnitus  aurium  and  a  feeling 
of  fulness  in  the  same  side  of  the  head  will  be  complained  of.  Pain 
may  or  may  not  be  present,  depending  much  upon  the  size  and  shape 
of  the  foreign  body,  upon  whether  or  not  it  is  organic,  alive,  or  is  of 
inorganic  structure.  Its  position  in  the  canal  in  relation  to  the  drum 
membrane  is  also  a  factor  as  to  the  presence  or  absence  of  suffering. 
In  general,  it  may  be  stated  that  the  presence  of  smooth  inorganic 
substances  like  pebbles,  beads,  or  buttons  give  rise  to  no  pain  unless 
they  are  so  large  as  to  make  pressure  on  the  canal  walls  or  unless  they 
have  entered  the  auditory  meatus  far  enough  to  lie  in  contact  with  the 
tympanic  membrane.  As  is  well  known,  this  membrane  is  exceedingly 
sensitive  and  pressure  upon  it  from  a  foreign  body  is  quite  intolerable. 
If  the  object  is  angular  or  rough  and  of  sufficient  size,  the  skin  of  the 
meatus  is  lacerated  during  the  entrance  of.  the  foreign  body,  and  this, 
together  with  the  inflammatory  reaction  that  follows,  is  usually  produc- 
tive of  considerable  suffering. 

The  presence  of  live  insects  is  intensely  painful  only  when  they  are 
impacted  against  the  drum  membrane  or  crawl  about  over  the  same, 
when  their  small  size  enables  them  to  do  so.  Insects  with  long  tentacles, 
which  spear  the  membrana  tympani  with  each  movement  of  the  head  in 
their  efforts  to  extricate  themselves  from  the  auditory  meatus,  cause  an 
agony  to  the  patient  probably  equalled  by  few  other  accidents.  The 
leguminous  seeds,  like  peas  and  beans,  and  certain  dried  fruits,  like 
currants,  usually  cause  little  disturbances  at  the  time  of  their  lodgment 
in  the  auditory  canal,  but  subsequently,  when  moisture  from  the  ad- 
joining tissues  is  absorbed,  the  object  swells  very  greatly  with  the  result 
of  impairment  of  function  and  the  production  of  tinnitus  and  pain. 


FOREIGN    BODIES    IN   THE   EXTERNAL   AUDITORY   MEATUS  14! 

Whereas  a  moderate-sized  smooth  body  may  lie  in  an  otherwise 
healthy  auditory  canal  indefinitely  without  apparent  injury,  should 
there  be  present  a  discharging  ear  at  the  time  of  the  lodgment  of  the 
same,  the  drainage  may  become  so  impaired  that  retention  of  pus  in 
the  middle  ear  may  result  and  severe  pain  be  the  inevitable  consequence. 
Such  an  obstruction  to  the  drainage  also  favors  an  extension  of  the 
suppurative  inflammation  to  the  mastoid  antrum  and  cells,  where  all 
the  dangers  incident  to  mastoiditis  may  subsequently  develop. 

Diagnosis. — There  is  but  one  safe  rule  to  follow  in  making  a  diag- 
nosis, and  that  is  to  actually  see  and  feel  with  a  probe  if  necessary  the 
object  which  lies  in  the  canal. 

Unfortunate  mistakes  have  been  made,  by  physicians  who  have 
ignored  this  one  certain  method  of  making  a  diagnosis.1  In  the  case 
of  children,  the  mother  has  perhaps  learned  from  the  playmates  that 
some  object  has  been  put  into  the  child's  ear.  In  her  excitement  she 
may,  on  her  journey  to  the  nearest  doctor's  office,  forget  which  ear  and 
therefore  insist  that  the  foreign  body  is  in  the  wrong  ear;  or  possibly 
the  object  which  is  presumably  in  the  canal  is  small  and  has  consequently 
dropped  out  before  the  surgeon  is  reached.  In  either  case,  if  the  physi- 
cian does  not  actually  see  the  object  himself,  he  may  make  the  error 
of  attempting  to  remove  the  body  from  the  wrong  ear;  or,  what  is  equally 
bad,  he  may  attempt  the  blind  extraction  of  an  object  which  has  already 
fallen  from  the  meatus. 

The  surgeon's  first  duty  is  to  quiet  all  feeling  of  excitement  on  the 
part  of  those  most  concerned.  The  child  that  has,  perhaps,  been  snatched 
from  its  play  and  hurried  to  the  physician's  office  by  an  unduly  anxious 
parent,  sometimes  accompanied  by  an  entire  household,  naturally 
expects  severe  treatment,  is  usually  much  frightened,  and  therefore 
tact  on  the  part  of  the  physician  and  an  explanation  of  the  fact  to  the 
parents  that  all  should  end  well,  and  a  quiet  kindly  demeanor  toward 
the  child  are  great  aids  toward  securing  the  confidence  of  the  patient 
and  enabling  the  surgeon  to  make  a  painless  examination. 

If  seen  before  rude  methods  of  extraction  have  been  practised  by 
which  the  object  has  been  pushed  deeply  inward,  very  commonly  the 
reflection  of  light  into  the  meatus  at  the  same  moment  of  the  retraction 
of  the  auricle  will  show  the  foreign  body  lying  in  the  outer  portion  of 
the  canal.  If  not  so  superficially  located  the  speculum  is  introduced 

1  An  instance  is  recorded  (British  Medical  Journal,  1877)  of  a  physician  who  explored 
an  ear  for  a  half-hour  in  his  efforts  to  dislodge  a  foreign  body  supposed  to  be  in  the  audi- 
tory meatus.  Pieces  of  bone,  but  no  foreign  objects  were  extracted.  The  child  died  from 
hemorrhage  in  an  hour  and  a  half  as  the  result  of  the  rude  and  unnecessary  efforts  of  the 
surgeon. 


142  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

in  the  usual  way  and  the  canal  illuminated,  when  every  portion  of  the 
deeper  parts  should  be  seen  without  difficulty  and  the  nature  and  position 
of  the  object  is  discovered.  When  small,  it  will  most  likely  lie  at  the 
bottom  of  the  canal,  near  the  annulus  tympanicus  at  its  lower  portion, 
but  if  large  it  may  obscure  the  greater  portion  or  even  all  of  the  membrana 
tympani.  If  any  doubt  as  to  the  nature  of  the  object  should  arise, 
assistance  may  be  obtained  by  using  a  probe  or  other  instrument  as 
an  aid  to  the  inspection.  Should  the  patient  be  an  unruly,  frightened 
child,  the  insertion  of  any  instrument  either  for  the  purpose  of  examina- 
tion or  extraction  is  often  wisely  withheld  until  the  patient  is  under 
the  influence  of  a  general  anesthetic. 

Where  unsuccessful  efforts  to  extract  the  foreign  body  have  been 
previously  made,  the  diagnosis  may  be  difficult  or  impossible,  for  the 
reasons  that  blood  may  be  oozing  from  the  canal  as  a  result  of  injury 
from  the  rude  manipulation,  or  the  walls  of  the  meatus  may  be  so  swollen 
as  to  partly  or  wholly  occlude  the  lumen  of  the  auditory  canal.  Under 
such  circumstances  it  is  more  humane  and  expedient  to  make  no  further 
efforts  at  diagnosis  except  under  a  general  anesthetic. 

Prognosis. — The  prognosis  as  to  life  is,  with  rare  exceptions,  good 
and  as  to  function  is  also  good  in  the  vast  majority  of  cases,  the  hearing 
being  preserved  unless  the  injury  is  severe  or  attempts  at  removal  have 
been  unduly  rude.  Numerous  instances  are  recorded  in  which  foreign 
bodies  have  remained  in  the  ear  for  many  years  without  causing  any 
disturbance  whatever.  In  such  cases  the  objects  were  usually  small, 
smooth,  inorganic  substances,  such  as  pebbles,  pieces  of  pencil,  beads, 
etc.1  Death  may  result  from  the  lodgment  of  a  bullet  or  other  substance 
which  fractures  the  skull  by  its  entrance  or  which  opens  the  jugular  bulb, 
lateral  sinus,  or  carotid  artery,  all  of  which  vessels  approach  the  auditory 
canal  closely  at  some  portion  of  its  course  (see  Fig.  304,  p.  550). 
Permanent  impairment  of  hearing  may  result  from  the  impaction  of  a 
foreign  body  against  the  drum  membrane  with  such  force  as  to  partially 
or  wholly  destroy  the  structure  and  perhaps  dislocate  the  ossicles.  Follow- 
ing such  an  injury  inflammation  of  the  tympanic  mucous  membrane 
with  suppuration  quickly  follows,  and  because  of  the  impediment  to  the 

1  The  Medicinische  Zeitung,  1842,  No.  32,  speaks  of  a  girl  in  whose  ear  a  piece  of 
pencil  remained  harmless  for  seven  years.  Haug  narrates  a  case  in  which  two  glass  beads 
remained  harmless  in  the  auditory  meatus  for  twenty-eight  years,  while  Winterbotham 
(Medical  Times  and  Gazette,  1866)  cites  an  instance  of  a  cherry-stone  which  remained 
harmless  in  the  auditory  meatus  for  about  sixty  years. 

Numerous  deaths  have  been  reported  to  follow  efforts  made  for  the  extraction  of 
foreign  bodies  from  the  auditory  meatus.  Poulet  cites  three  such  deaths  in  which  men- 
ingitis followed  the  extraction.  Clermont  recites  a  case  in  which  death  occurred  very 
soon  after  the  removal  of  a  pin  from  the  auditory  canal. 


FOREIGN    BODIES   IN   THE   EXTERNAL   AUDITORY   MEATUS  143 

outflow  of  pus  produced  by  the  blocking  of  the  foreign  body,  mastoid  or 
intracranial  complication  sometimes  quickly  ensues,  and  death  from  one 
of  these  affections  may  ultimately  result.  In  case  the  labyrinth  is 
involved  the  hearing  suffers  greatly  and  total  deafness  in  the  affected 
side  may  result. 

Treatment. — Briefly  stated,  the  treatment  consists  in  the  removal  of 
the  foreign  body.  As  previously  mentioned  it  is  entirely  possible  for 
such  a  body  to  remain  in  the  canal  indefinitely  without  the  slightest 
discomfort  or  danger,  and  therefore  in  any  case,  if  it  is  known  to  be  of 
only  moderate  size,  inorganic  in  structure,  and  smooth  in  contour,  the 
case  can  scarcely  be  classed  as  an  emergency,  and  hence  wiU  not  require 
such  precipitous  haste  in  the  removal  of  the  body  as  to  preclude  the 
selection  of  a  time  when  all  necessary  preparations  may  be  made  to 
execute  the  work  most  easily  and  safely. 

When  the  object  to  be  removed  is  small  and  perhaps  lies  deeply  in 
the  canal,  its  removal  is  best  and  most  easily  accomplished  by  syringing 
with  warm  sterile  water.  For  this  purpose  a  piston  syringe  (see  Fig.  84) 
should  be  used  which  holds  at  least  2  ounces.  The  auricle  is  retracted 


FIG.  80. — EAR-HOOK 

in  the  usual  way,  but  the  syringing  should  be  done  with  more  force  than 
is  employed  when  the  procedure  is  used  for  the  removal  of  pus  when  a 
perforation  of  the  membrana  tympani  is  present.  When  the  above 
simple  technic  is  followed  the  foreign  body  will  be  dislodged  and  washed 
from  the  canal  in  practically  all  cases  of  this  class. 

If  the  preliminary  examination  has  shown  the  substance  to  be  a  wad 
of  paper,  cotton,  or  other  similar  substance,  it  may  be  most  conveniently 
withdrawn  by  any  slender  dressing-forceps  such  as  are  shown  in  Fig.  214, 
p.  348.  A  flat  button  or  other  similarly  shaped  article,  which  is  so 
placed  that  the  edge  presents  itself  toward  the  concha,  may  likewise 
be  removed  with  these  instruments.  A  button  having  either  a  ring  or 
an  eye  may  be  so  situated  that  any  conveniently  shaped  tenaculum  or 
hook  (Fig.  80)  can  be  inserted  into  the  ring  and  the  object  be  thereby 
easily  removed. 

Whatever  the  object  may  be,  it  should  be  the  aim  of  the  operator  not 
to  push  it  farther  into  the  meatus  during  any  attempt  at  removal.  Every 
manipulation  should  be  made  under  the  full  illumination  of  the  object 


144  THE   PRINCIPLES    AND    PRACTICE   OF   OTOLOGY 

by  reflected  light,  and  both  foreign  body  and  instrument  must  be  seen 
by  the  operator  at  all  times  during  the  progress  of  the  removal. 

In  the  case  of  round,  smooth  bodies,  like  beads  or  beans,  whose 
size  is  sufficient  to  entirely  fill  the  meatus,  it  is  particularly  unfortunate 
to  push  them  beyond  the  isthmus  during  awkward  efforts  at  extraction, 
because  while  they  yet  lie  in  a  position  external  to  the  narrowed  portion 
of  the  canal  (Fig.  81,  a),  they  are  comparatively  easy  to  dislodge,  whereas, 
if  pushed  beyond  this  point  (Fig.  81,  b),  the  difficulties  are  greatly  multi- 
plied, and  sometimes  detachment  of  the  auricle  may  be  necessary  to 
remove  them  from  the  deep  and  impacted  situation.  Objects  of  this 
character,  which  are  spheric  or  ovoid  and  whose  surfaces  are  polished, 
cannot  be  grasped  in  the  jaws  of  any  forceps,  and  it  is  not  wise  to 
attempt  the  use  of  this  instrument  in  their  extraction  because  the  result 


Malleus  — 
Drum  membrane  — 


FIG.  81. — BEAN  IN  EXTERNAL  AUDITORY  MEATUS. 

a  Shows  most  usual  location  of  large  foreign  body  before  unskilful  attempts  at  extraction  have  been  made ; 
b  shows  body  after  it  has  been  pushed  beyond  the  isthmus  of  the  canal. 

is  always  the  same,  namely,  that  when  the  jaws  are  closed  upon  the  sur- 
face the  foreign  body  only  slips  out  and  is  thereby  pushed  the  farther 
inward,  until  finally  it  is  unfortunately  jammed  through  the  tympanic 
membrane  and  against  the  inner  tympanic  wall.  The  only  kinds  of 
instruments  that  can  be  used  successfully  in  such  cases  are  tenacula  with 
short,  sharp  hooks,  which  in  the  case  of  objects  like  beans  can  be  im- 
bedded directly  into  the  substance  (Fig.  82)  and  their  removal  accom- 
plished by  traction,  or  those  with  a  mechanically  movable  distal  ex- 
tremity (Fig.  83),  which  can  be  passed  along  the  canal  wall  to  a  point 
beyond  the  object,  after  which  an  elbow  is  constructed  at  the  innermost 
end  of  the  instrument  by  compressing  the  spring  at  the  outer  end,  and 
then  traction  is  efficiently  made  against  the  object,  which  is  thus  easily 
and  safely  removed. 


FOREIGN    BODIES    IN    THE    EXTERNAL    AUDITORY    MEATUS 


145 


The  removal  of  live  insects  is  immediately  imperative  because  of 
the  intense  pain  their  presence  and  movement  causes,  and  also  because 
if  the  insect  is  large  and  powerful  and  is  armed  with  tentacles,  as  is 


FIG.  82. — REMOVAL  OF  FOREIGN  BODY  BY  MEANS  OF  A  DELICATE  TENACDLUM. 

The  auditory  meutus  is  straightened  by  upward  and  backward  traction  upon  the  auricle.     The  deep  situation 
of  the  object  requires  the  insertion  of  the  aural  speculum. 

sometimes  the  case,  much  injury  and  subsequent  inflammatory  reaction 
may  result  to  the  drum  membrane.  If  not  impacted  the  insect  can  be 
successfully  syringed  from  the  canal  just  as  in  the  case  of  any  other 


FIG.  83. — QUIRE'S  FOREIGN  BODY  EXTRACTOR. 

foreign  body.  If  this  does  not  succeed  or  if  impaction  has  occurred, 
the  insect  should  be  quickly  killed,  or  at  least  stupefied,  so  as  to  prevent 
its  further  painful  movement.  Chloroform  vapors  or  chloroform  itself  is 
sufficient  for  these  purposes.  Some  thick  oil,  like  melted  vaselin,  should 
10 


146  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

first  be  poured  into  the  ear,  after  which  a  pledget  of  cotton  large  enough  to 
fill  the  meatus  is  saturated  with  chloroform  and  inserted  into  the  canal 
against  the  insect.  In  order  to  confine  the  chloroform  so  as  to  obtain 
its  rapid  and  more  certain  effect,  a  second  piece  of  oiled  cotton  is  inserted 
air-tight  on  top  of  that  containing  the  chloroform.  The  melted  vaselin 
is  used  to  coat  the  drum  membrane  and  walls  of  the  meatus,  and  to 
thus  prevent  irritation  or  blistering  of  the  parts  by  the  chloroform  which 
is  subsequently  inserted.  The  insect  is  quieted  almost  at  once  and 
can  then  be  removed  by  the  forceps  either  whole  or  piecemeal. 

The  question  as  to  the  necessity  for  the  administration  of  an  anesthetic 
sometimes  arises  and  must  be  settled  in  each  case  according  to  the 
probable  behavior  of  the  individual  and  the  suffering  or  difficulties  that 
are  likely  to  arise  during  the  removal  of  the  foreign  body.  In  a  patient 
of  ordinary  self  control  and  one  in  whom  the  foreign  body  is  not  impacted 
in  a  position  beyond  the  isthmus  of  the  external  auditory  meatus,  an 
anesthetic  is  never  necessary.  If  the  patient  is  apprehensive  and 
highly  nervous,  particularly  if  a  child,  or  if  previous  unsuccessful  at- 
tempts at  extraction  have  been  made  during  which  the  canal  has  been 
injured  and  is  now  swollen,  the  administration  of  ether  or  chloroform 
is  undoubtedly  indicated.  Under  its  influence  the  use  of  all  instruments 
should  be  guided  by  a  good  illumination  from  a  head-mirror  and  the 
manipulations  should  be  conducted  as  skilfully  and  as  gently  as  if  the 
patient  were  wholly  conscious,  for  only  by  this  amount  of  care  is  it  pos- 
sible to  avoid  wounding  the  skin  of  the  canal  or  perforating  the  drum 
membrane. 

In  rare  instances  the  object  is  found  so  firmly  impacted  that  it  is 
impossible  to  remove  it  through  the  auditory  meatus,  in  which  case 
the  auricle  is  detached  by  steps  quite  similar  to  those  followed  in  the 
first  stages  of  the  radical  mastoid  operation  (see  Fig.  238  and  p.  382). 
This  operation  is  safe,  successful,  and  results  in  practically  no  scar. 


CHAPTER  XIII 
IMPACTED    CERUMEN 

A  COLLECTION  of  ear-wax  in  the  external  auditory  meatus  is  frequently 
observed.  The  cause  of  such  an  accumulation  is  either  a  retention  of 
the  normal  amount  of  secretion  or  an  excess  of  secretion.  The  ceru- 
minous  glands  are  found  almost  wholly  in  the  cartilaginous  portion  of 
the  canal  and  the  wax  is  normally  expelled  by  the  motions  of  the  lower 
jaw,  the  articulation  of  which  lies  immediately  under  the  cartilaginous 
portion  of  the  external  auditory  meatus.  Since  this  portion  of  the 
meatus  slopes  downward  and  outward  from  within,  the  expulsion  of  the 
secretion  is  somewhat  facilitated  by  gravity.  When  the  cutaneous  lining 
of  the  meatus  is  inflamed  from  any  cause,  it  becomes  roughened  because 
of  the  exfoliation  of  its  superficial  epithelia,  and  this  forms  not  only  a 
barrier  to  the  outward  progress  of  the  wax,  but  the  epithelia  are  also 
incorporated  with  it,  increasing  its  consistency  and  thus  in  a  twofold 
way  favoring  its  retention. 

A  long-continued  eczema  or  other  inflammation  of  the  canal  often 
results  in  contracting  the  lumen  almost  to  the  point  of  stricture.  An 
exostosis  or  foreign  body  lodged  in  the  external  auditory  meatus  may 
narrow  or  even  obliterate  the  passage.  All  these  and  other  causes  of 
obstruction  to  the  canal  are  causative  factors  in  the  retention  and  sub- 
sequent impaction  of  cerumen. 

Symptoms. — Collections  of  cerumen  of  very  considerable  size  are 
often  observed  in  the  auditory  canal  of  an  individual  who  makes  no 
complaint  whatever  of  any  aural  disturbance.  Indeed,  if  the  organ  of 
hearing  is  otherwise  normal,  the  accumulation  of  wax  creates  little 
or  no  inconvenience,  as  a  rule,  until  it  completely  blocks  the  lumen  of 
the  passage,  or  unless  it  is  dislodged  and  carried  inward  against  the  drum 
membrane.  Patients  frequently  state  that  a  few  hours  previously  they 
heard  normally  and  thought  they  had  no  aural  ailment  of  any  kind,  but 
that,  while  cleansing  the  ear  during  the  morning  toilet,  sudden  deaf  ness 
and  dizziness  came  on,  and  that  as  a  result  great  apprehension  of  damage 
to  the  ear  is  felt.  In  all  such  instances  the  auditory  canal  had  previously 
been  almost  completely  filled  with  a  ceruminous  mass  through  which 
an  opening  persisted  sufficiently  large  to  permit  the  passage  of  sound- 
waves and  of  air  for  the  equalization  of  pressure  upon  the  outer  side  of 

147 


148  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

the  drum  membrane.  While  the  patient  was  cleansing  the  ear  water 
had  entered  the  meatus,  had  caused  softening  and  swelling  of  the  ceru- 
minous  mass,  after  which  the  manipulations  of  the  finger,  hand,  and 
towel  in  and  about  the  ear  had  spread  the  wax  across  the  opening  of  the 
canal,  had  thus  sealed  the  fundus  of  the  ear  from  external  influences, 
and  had  in  this  way  brought  on  the  sudden  deafness. 

Another  class  will  state  that  the  deafness  has  been  coming  on  grad- 
ually for  months  or  years,  but  that  at  times  the  symptoms  are  much 
improved  only  to  relapse  again  into  a  worse  condition.  This  variation 
of  symptoms  is  due  to  the  fact  that  there  is  present  a  middle-ear  or 
labyrinthine  deafness,  as  well  as  an  obstruction  to  the  sound-waves  by 
the  wax  plug. 

Whatever  may  be  the  causation,  when  the  canal  is  once  tightly 
blocked  certain  similar  symptoms  will  always  develop  at  once.  These 
are  marked  deafness,  tinnitus  aurium,  a  feeling  of  heaviness  on  the  affected 
side  of  the  head;  and  less  frequently  vertigo,  mental  depression,  and 
vomiting.  A  dry,  hacking  cough  is  sometimes  produced  by  the  presence 
of  hardened  ear  wax.  Pain  is  seldom  present  except  in  cases  where 
the  wax  has  become  greatly  hardened  and  has  lain  in  the  canal  under 
a  pressure  sufficient  to  cause  ulceration  of  the  adjoining  walls.  Pain 
may  also  result  from  the  dislodgment  of  a  hardened  mass,  which  is  later 
driven  inward  and  becomes  impacted  against  the  tympanic  membrane. 

Diagnosis. — The  diagnosis  is  nearly  always  easily  made  by  follow- 
ing the  methods  given  in  detail  for  the  inspection  of  the  external 
auditory  meatus  (see  p.  169).  WThen  the  auricle  is  retracted  and  the 
reflected  light  is  thrown  into  the  meatus,  the  mass  is  seen  as  a  grayish- 
black  or  brownish  object  which  partly  or  wholly  obstructs  the  passage. 
Inspissated  cerumen  may  be  mistaken  for  a  foreign  body  which  is 
incrusted  with  wax,  or  for  dried  pus  which  has  accumulated  in  the 
external  auditory  meatus  in  cases  of  chronic  purulent  otitis  media. 
This  latter  condition  occurs  after  the  discharge  has  diminished  to  a 
mere  trifle  and  is  too  scanty  to.  appear  at  the  outer  meatus,  where  it 
would  be  observed  and  wiped  away  by  the  patient.  Such  a  collection 
of  dried  pus  is  usually  found  on  the  superoposterior  wall  of  the  canal 
at  its  junction  with  the  membrana  tympani,  in  which  location  it  some- 
times incrusts  the  adjoining  wall  of  the  meatus  to  a  thickness  which 
may  obscure  the  view  of  the  whole  upper  portion  of  the  drum  membrane 
(p.  331,  Fig.  189).  Sometimes  it  becomes  necessary  to  supplement 
the  inspection  of  the  canal  with  the  use  of  the  probe,  which  instrument 
is  always  safe  and  valuable  when  carefully  used  under  the  guidance  of 
the  eye  and  a  good  reflected  light. 


IMPACTED    CERUMEN 


149 


Prognosis. — Impacted  ear-wax  is  in  no  sense  a  dangerous  condition, 
except  in  very  rare  cases  where  it  complicates  a  middle-ear  suppuration, 
in  which  instance  its  presence,  acting  as  a  hindrance  to  good  drainage, 
might  lead  to  such  serious  consequences  as  mastoid  extension  or  intra- 
cranial  complication. 

Recurrence  of  the  accumulation  after  its  removal  is  the  rule.     The 
patient  should  be  told  that  a  repetition  of  the  trouble  should  be  expected 
after  a  period  of  from  six  weeks  to  a  year  or  more,  so  that  he  may  in 
the  future  be  sufficiently  informed    to  seek  relief 
earlier  than  he  might  otherwise  do. 

The  prognosis  as  to  hearing  is  always  good  in 
those  cases  where  the  impairment  occurred  sud- 
denly. In  all  who  have  grown  gradually  worse, 
or  who  state  that  they  are  better  and  worse,  there 
is  usually  a  labyrinthine  or  middle-ear  complica- 
tion, and  hence  a  favorable  prognosis  should  not  be 
given  until  after  a  thorough  physical  and  func- 
tional examination  has  been  made.  Should  all 
observations  of  the  condition  of  the  fundus,  to- 
gether with  the  facts  obtained  by  the  tuning-forks, 
show  that  there  is  present  a  disease  either  of  the 
conducting  or  perceiving  portion  of  the  hearing 
organ,  an  unfavorable  or,  at  least,  a  very  guarded 
prognosis  should  be  made. 

Treatment. — Hardened  wax  is,  in  effect,  a 
foreign  body,  and  therefore  the  treatment  should 
consist  in  its  removal  and,  where  possible,  in  a 
prevention  of  its  recurrence.  When  the  impacted 
cerumen  is  soft  and  does  not  completely  block  the 
canal,  its  removal  by  means  of  syringing  the  canal 


FIG.  84. — METAL  SYRINGE. 
The  sharp  point  is  ser- 
viceable in  syringing  around 

is  the  simplest  and  safest  procedure  and  the  one     foreign  bodies  and  hardened 
to  be  recommended. 


wax  in  the  auditory  canal. 


For  the  purpose  of  removing  hardened  ear-wax  a  large  piston- 
syringe  is  preferable  (Fig.  84).  If  the  patient's  ear  is  retracted  as 
shown  in  Fig.  94  and  the  fluid  is  injected  from  the  syringe  with  con- 
siderable force,  the  accumulation  of  cerumen  will  be  quickly  dislodged, 
and  very  seldom  will  it  be  necessary  to  have  the  patient  return  because 
the  first  attempt  has  proved  unsuccessful.1 

1Pomeroy  (Diseases  of  the  Ear)  says,  "I  feel  sure  that  the  power  of  the  syringe  for 
removing  cerumen,  and  a  great  variety  of  foreign  bodies  from  the  ear,  is  not  sufficiently 
appreciated  by  the  profession.  As  long  as  a  considerable  amount  of  cerumen  remains  in 
the  ear  to  protect  the  membrane  I  have  not  the  slightest  fear  of  doing  harm  by  the  syringe." 


150  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

The  fluid  used  for  syringing  should  always  be  sterile  or  antiseptic, 
for  the  reason  that  it  can  never  be  known  beforehand  whether  or  not 
the  drum  membrane  is  perforated,  and  should  a  perforation  be  present, 
and  the  operator  use  an  indifferently  prepared  solution,  an  old  quiescent 
tympanic  inflammation  may  thereby  be  revived  and  suppuration  follow 
the  removal  of  the  wax.  Normal  salt  solution1  or  a  saturated  solution 
of  boric  acid  is  always  satisfactory  when  properly  prepared.  The 
temperature  of  solutions  intended  for  syringing  the  ear,  especially  for 
the  removal  of  hardened  wax,  should  be  as  high  as  can  be  comfortably 
borne  by  the  back  of  the  hand. 

Neither  physician  nor  patient  should  ever  immerse  the  hand  or 
fingers  in  any  surgical  solution  for  the  purpose  of  testing  the  temperature. 
For  this  purpose  a  dairy  thermometer  is  useful  or,  what  is  equally 
serviceable,  is  to  suck  up  with  the  syringe  a  quantity  of  the  solution  and 
allowr  it  to  drop  on  the  back  of  the  hand.  An  accurate  judgment  as  to 
the  proper  temperature  will  in  this  way  soon  be  acquired. 

When  the  canal  is  completely  filled,  and  the  surface  of  the  cerumen 
has  become  dry,  hard,  and  glazed,  the  solution  cannot  be  thrown  behind 
the  mass,  and  hence  syringing  alone  will  not  suffice  for  its  effectual 
dislodgment.  When  this  fact  is  evident,  under  reflected  light  a  small 
spatula  or  hook  may  be  inserted  between  some  portion  of  the  canal 
wall  and  the  wax,  and  the  latter  so  separated  from  the  former  as  to 
make  a  passage  through  which  the  injected  fluid  can  pass.  During 
subsequent  efforts  at  syringing,  the  nozzle  of  the  instrument  is  pointed 
toward  the  crevice  thus  produced  and  the  stream  of  water  is  injected 
somewhat  forcibly  through  it.  By  this  means  the  ceruminous  plug  is 
often  quickly  brought  away  in  a  mass,  which  retains  the  shape  of  that 
portion  of  the  auditory  canal  in  which  it  lay. 

If  not  successful  in  the  removal  by  the  above  means,  other  portions 
of  the  wax  may  be  still  further  separated  from  the  canal  until,  possibly, 
the  whole  circumference  has  been  thus  detached.  Then  the  syringing 
may  again  be  resumed  or,  if  thought  best,  the  outer  end  of  the  mass 
may  be  grasped  in  the  jaws  of  an  aural  dressing-forceps  and  the  whole 
be  by  this  means  withdrawn. 

Cases  are  sometimes  seen  in  which  these  methods  fail  or  seem  inju- 
dicious because  the  ulcerated  underlying  skin  is  too  sensitive  to  tolerate 
even  the  most  gentle  manipulations.  In  such  instances  it  is  proper  to 
provide  the  patient  with  an  antiseptic  alkaline  lotion,  with  instructions 

'Normal  salt  solution  contains  o  65  per  cent,  of  sodium  chlorid  or  49.9  gr.  to  .^xvj. 
For  practical  purposes  in  aural  treatment  it  may  be  quickly  prepared  by  adding  a  level 
teaspoonful  of  common  salt  to  i  pint  of  boiled  water. 


IMPACTED    CERUMEN  151 

to  drop  the  same  into  the  meatus  twice  a  day  for  one  or  more  days. 
At  the  return  visit  of  the  patient  the  wax  will  usually  be  found  so  much 
softened  that  it  may  be  readily  syringed  away,  as  above  directed. 
A  satisfactory  lotion  for  softening  inspissated  cerumen  consists  of: 

H  .  Acid,  carbolic.,  gr.  ij  ; 

Sodium  bicarb., 

Sodium  biborate,  da  gr.  x  ; 

Glycerin,  $  ss ; 

Aquae  destil.,  ad  qs.  553. — M. 

Sig.   Warm  and  drop  10  drops  into  the  ear  twice  a  day  and  allow  to  remain. 

Following  the  removal  of  the  plug,  an  examination  of  the  canal 
walls  and  fundus  of  the  ear  is  essential  for  the  purpose  of  determining 
the  amount  of  damage  its  presence  may  have  done,  and  also  to  ascertain 
whether  or  not  the  drum  membrane  is  perforated  or  otherwise  diseased. 
Hence  the  parts  should  be  thoroughly  dried  by  the  introduction  into  the 
canal  of  cotton  cylinders  (Fig.  203),  and  if  ulcerations  are  anywhere 
detected  they  should  be  touched  with  silver  nitrate,  after  which  the  whole 
canal  may  be  lightly  dusted  with  boric  acid  powder.  The  dressing 
is  completed  by  inserting  a  gauze  wick  or  a  pledget  of  cotton  into  the 
canal,  either  of  which  may  be  removed  after  twenty-four  hours.  Neglect 
of  these  precautions,  as  to  treatment  after  the  removal  of  impacted 
cerumen,  will  sometimes  result  in  an  acute  general  or  circumscribed 
inflammation  of  the  canal  (see  Chapter  IX.). 


CHAPTER  XIV 
EXOSTOSES    OF    THE    EXTERNAL    AUDITORY  MEATUS 

WHILE  osseous  outgrowths  from  the  walls  of  the  bony  meatus  are  not 

of  common  occurrence,  yet  every  physician  who  frequently  examines 

the  ear  must  occasionally  see  this  class  of  tumor. 

Symptoms. — In  most  instances  when  the  bony  outgrowth  is  small, 

the  patient  will  have  no  knowledge  of  its  existence,  and  will  make  no 
complaint  whatever  concerning  the  ear  in 
which  it  grows  (Fig.  85).  Even  if  it  is  large 
enough  to  greatly  occlude  the  canal  its  presence 
may  not  have  been  recognized,  unless  some 
other  disease  attacks  the  middle  ear  or  the  audi- 
tory canal  itself.  Should  suppuration  occur  in 
the  middle  ear,  the  growth  when  large  be- 
comes an  obstruction  to  the  free  outflow  of 
pus,  pain  will  result  from  the  retention  of  the 

FIG.  SS.-SMALL  PEDUNCCLATED     latter,  and  ulceration  and  swelling  of  the  deli- 

EXOSTOSIS  TWICE  ENLARGED. 

viewed  through  speculum.        cate  integument  of  the  meatus  will  likely  occur 

from  the  same  cause. 

The  effect  on  the  hearing  depends  entirely  upon  the  size  of  the 
exostosis  and  upon  whether  or  not  it  is  complicated  by  some  inflamma- 
tory disease  of  the  canal  or  middle  ear.  When  too  small  to  occlude 
the  lumen  of  the  canal,  and  when  uncomplicated  by  any  other  aural 
ailment,  an  exostosis  has  no  effect  whatever  on  the  function.  When 
the  growths  are  multiple  or  when  a  single  one  is  of  great  size,  the  auditory 
meatus  may  be  so  blocked  that  sound-waves  no  longer  reach  the  mem- 
brana  tympani,  in  which  instance  a  high  degree  of  deafness  in  the 
affected  ear  may  result. 

Physical  Examination. — No  external  swelling  or  deformity  of 
any  kind  accompanies  an  exostosis  of  the  meatus.  If  situated  at  the 
outer  end  of  the  osseous  canal  a  view  of  the  tumor  may  sometimes  be 
obtained  by  placing  the  patient  in  a  strong  light  from  a  window  and 
simply  retracting  the  auricle.  However,  a  satisfactory  view  is  usually 
obtainable  only  by  the  use  of  the  head-mirror,  a  good  light,  and,  if  the 
growth  lies  deeply,  an  aural  speculum.  Most  usually  osteomata  appear 

152 


EXOSTOSES    OF   THE    EXTERNAL   AUDITORY   MEATUS  153 

as  hardened  outcroppings  from  the  walls  and  are  covered  with  skin 
that  is  much  thinner  and  paler  in  color  than  the  surrounding  integument. 
They  may  be  somewhat  pedunculated,  may  have  a  broad  base,  and 
may  be  single  or  multiple.  The  multiple  variety  will  usually  be  seen 
to  occupy  opposing  positions  around  the  meatal  walls  in  such  a  manner 
that  the  summit  of  each  projects  toward  the  summit  of  the  others 
(Fig.  86);  in  the  worst  cases  may  touch  each  other,  and,  because  of 
the  pressure-contact,  may  become  inflamed,  ulcerated,  and  adherent 
to  the  extent  of  completely  occluding  the  canal.  If  the  exostosis  is 
single,  and  moderate  in  size,  a  portion  of  the  membrana  tympani  may 
be  seen  (Fig.  85) ,  and  the  important  information  obtained  as  to  whether 
or  not  there  is  suppuration  going  on  within  the  middle  ear.  A  delicate 
probe  may  be  used  advantageously  in  determining  the  extent  of  the  base 
of  the  growth,  and  whether  or  not  the  same  is  sessile  (Fig.  87)  or  pedun- 
culated. 


FIG.  86. — MULTIPLE  OSTEOMATA  VIEWED  THROUGH  FIG.  87. — LARGE  SESSILE  EXOSTOSIS  VIEWED 

AN  AURAL  SPECULUM.     Twice  enlarged.  THROUGH  A  SPECULUM.     Twice  enlarged. 

Prognosis. — Exostoses  are  of  themselves  never  dangerous  to  life 
and  they  impair  the  hearing  only  when  large  enough  to  completely 
occlude  the  auditory  canal.  It  is  only  when  suppurative  processes  of 
the  middle  ear  are  coexistent  with  the  growth  in  the  canal,  or  when  sup- 
purative diseases  subsequently  ensue,  that  the  real  element  of  danger 
arises  from  their  presence,  because  then,  on  account  of  the  obstruction 
they  present  to  the  free  outflow  of  the  pus,  they  are  apt  to  favor  a  burrow- 
ing of  septic  material  toward  the  cranial  cavity. 

Treatment. — The  smaller  osteomata  need  no  treatment  in  so  far 
as  the  growth  itself  is  concerned,  but  such  cases  often  retain  the  cerumen 
to  an  extent  that  this  may  require  frequent  removal  at  the  hands  of  the 
physician.  If  the  growths  become  an  obstruction  to  the  canal  to  the 
extent  that  the  hearing  is  greatly  impaired;  if  by  their  pressure  upon  each 
other  they  become  ulcerated,  painful,  and  adherent;  and  particularly 
if  a  purulent  process  exists  in  the  middle  ear  or  mastoid  antrum,  their 
total  ablation  is  indicated  and  often  imperatively  demanded.  The 


154  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

smaller  pcdunculatcd  ones  may  be  removed  by  means  of  a  cold  wire 
snare  or,  better,  by  the  employment  of  a  long  delicate  gouge.  This 
latter  is  placed  in  proper  position  against  the  neck  of  the  tumor  at  its 
junction  with  the  wall  of  the  meatus,  under  good  illumination  and  the 
guidance  of  the  eye  of  the  operator,  when  a  few  gentle  strokes  of  the 
mallet  made  by  the  assistant  will  be  ample  to  cut  through  and  dislodge 
the  little  mass,  which  can  then  be  removed  by  means  of  a  dressing- 
forceps.  It  need  scarcely  be  stated  that  great  precaution  must  be  taken 
in  the  removal  of  these  growths,  by  any  method  that  may  be  chosen,  not 
to  drive  the  instrument  too  deeply  and  thereby  do  violence  to  the  drum 
membrane.  The  dental  drill  has  been  used  successfully  to  hollow  out 
or  entirely  grind  away  exostosic  masses.  However,  no  one  should 
undertake  the  operation  of  this  instrument  in  the  depths  of  the  auditory 
canal  unless  his  previous  experience,  with  less  harmful  tools,  has  given 
him  full  assurance  of  his  capability  of  using  the  burr  without  doing 
violence  to  adjoining  healthy  structures. 

The  question  of  a  general  anesthetic  must  be  considered  in  the  above 
operations.  Local  anesthesia  is  inefficient  and  ether  or  chloroform 
should  be  administered,  if  the  growth  is  of  any  considerable  size  or  if 
it  is  of  the  sessile  variety.  For  the  larger  and  multiple  exostoses  the 
removal  may  be  much  better,  and  certainly  more  safely  accomplished 
by  detaching  the  auricle  and  exposing  the  growths  to  the  extent  that 
the  field  of  operation  is  always  visible,  under  which  conditions  the 
ablation  can  be  more  efficiently  and  safely  performed.  Since  the 
operation  of  displacement  of  the  auricle  is  performed  not  only  for  the 
removal  of  exostosis  but  also,  sometimes,  for  the  extraction  of  impacted 
foreign  bodies  from  the  fundus  of  the  canal,  and  for  the  removal  of 
fibrous  septa  or  adhesions,  a  description  of  the  technic  of  its  performance 
is  here  given,  to  which  reference  will  subsequently  be  made  when  clear- 
ness of  description  may  demand. 

Detachment  oj  the  Auricle. — The  hair  is  first  cut  short  and  then 
shaven  around  the  auricle  for  a  distance  of  2  inches  in  every  direction 
or,  if  great  objection  is  offered  to  the  loss  of  hair,  it  may  be  combed  as 
much  away  from  the  pinna  as  possible  and  then  covered  by  the  applica- 
tion of  collodium  for  a  distance  of  3  inches  around  the  pinna.  The 
external  auditory  meatus  is  syringed  with  an  antiseptic  fluid,  and  the 
skin  over  the  exposed  area  is  scrubbed  and  sterilized  just  as  in  the 
preparation  for  the  mastoid  operation  (see  p.  290).  The  patient  is 
anesthetized  by  the  administration  of  ether  or  chloroform.  Every 
antiseptic  precaution  should  be  taken  in  the  way  of  protecting  the 
operative  field  from  infection,  just  as  would  be  done  were  a  much  more 


EXOSTOSES   OF   THE    EXTERNAL    AUDITORY   MEATUS  155 

extensive  surgical  procedure  contemplated,  because  it  is  highly  desirable 
to  secure  a  union  by  first  intention  of  all  the  incised  tissues.  The 
initial  incision  is  made  exactly  as  shown  in  Fig.  158,  p.  292,  and  the 
underlying  bone  is  uncovered  to  the  extent  that  is  shown  in  Fig.  240, 
p.  383.  It  will  be  noticed  that  the  skin,  cartilage,  and  periosteum 
of  the  posterior,  posterosuperior,  and  posteroinferior  walls  of  the  external 
meatus  is  detached  entirely  from  the  bone  in  these  locations  to  a  point  in 
depth  beyond  the  growth  or  object  to  be  removed.  The  skin  covering 
the  osteoma  may  be  adherent,  in  which  case  it  will  require  an  extra 
amount  of  care  to  detach  it  without  breaking  it  through.  As  the  operator 
approaches  the  depth  at  which  the  drum  membrane  lies  a  still  greater 
caution  should  be  exercised  not  to  injure  this  structure.  When  the 
dissection  of  the  auditory  meatus  is  satisfactorily  completed,  every 
bleeding  point  must  be  secured  and  the  whole  wound  subsequently 
dried  by  firmly  packing  it  with  gauze.  The  bleeding  having  ceased, 
the  edges  of  the  flaps  are  widely  retracted  (Fig.  240,  p.  383),  and  with 
a  small  gouge  and  mallet  the  exostoses  are  chipped  away  not  only  down 
to,  but  somewhat  beyond,  their  bases.  It  has  been  found  that  the  audi- 
tory canal  has  some  tendency  to  contract  after  these  operations,  and 
hence  it  is  wisest  to  remove  the  bone  deeply,  rather  than  to  err  in  the 
opposite  direction  and  thus  run  the  risk  of  a  subsequently  narrowed 
meatus.  It  is  sometimes  advisable,  in  cases  of  osteosclerosis  of  the 
whole  bony  meatus,  to  hollow  a  channel  throughout  the  whole  length 
of  the  osseous  portion  of  the  posterior  canal  wall,  and  then  to  line  the 
same  by  first  splitting  the  posterior  meatal  tissues  of  the  soft  canal,  and 
afterward  tucking  the  flaps  thus  produced  backward  into  place,  and 
holding  them  there  by  means  of  a  gauze  packing  inserted  into  the 
auditory  meatus  until  they  adhere  to  their  new  position  in  the 
enlarged  auditory  canal.  The  cases  in  which  extensive  removal 
of  bone  is  practised  are  much  more  likely  to  result  satisfactorily 
than  are  those  in  which  a  contracted  canal  is  left  subsequently  to  the 
operation. 

If  detachment  of  the  auricle  is  performed  for  the  purpose  of  removing 
either  a  foreign  body  or  adhesions  within  the  canal  it  is  necessary,  after 
completing  the  dissection  of  the  soft  structures  from  the  bone,  to  slit 
the  former  lengthwise  to  a  sufficient  distance  to  permit  the  extraction 
of  the  impacted  object.  In  some  cases,  where  the  foreign  body  is  large 
and  therefore  very  firmly  wedged  into  the  fundus  of  the  canal,  it  may 
be  necessary  to  chisel  away  a  portion  of  the  posterior  osseous  canal 
wall  before  extraction  is  possible.  Any  necessary  enlargement  for  this 
purpose  adds  nothing  to  the  subsequent  gravity  of  the  case,  and  should 


156  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

be  made  at  once  when  seen  to  be  required,  rather  than  to  persist  in 
efforts  at  unsuccessful  extraction  through  the  contracted  channel. 

After  the  accomplishment  of  the  purpose  for  which  the  detachment 
of  the  auricle  was  performed,  the  postauricular  structures  are  accurately 
replaced  into  the  bony  meatus,  and  a  strip  of  gauze  f  inch  wide  is  in- 
serted into  the  auditory  canal  with  sufficient  firmness  to  hold  them  in 
snug  contact  with  the  denuded  surfaces.  This  dressing  need  not  be 
changed  for  three  or  four  days,  at  the  end  of  which  time  the  adhesion 
of  the  dissected  portions  of  the  canal  walls  should  be  complete.  The 
postauricular  incision  is  stitched  throughout  its  entire  extent,  exactly  as 
is  described  on  p.  395,  Fig.  253,  and  it  will  unite  by  first  intention  if 
the  surgical  technic  has  not  been  faulty.  If  the  hearing  was  previously 
good  it  will  remain  so  after  this  operation,  unless  unnecessary  damage 
has  been  committed  by  some  step  of  the  procedure.  If  the  hearing 
was  previously  impaired  or  lost,  and  the  middle  ear  and  labyrinth 
were  not  involved,  the  hearing  should  be  greatly  improved  by  the 
removal  of  the  obstruction  from  the  auditory  canal. 


CHAPTER  XV 

CARIES  OF  THE  WALLS  OF  THE  EXTERNAL  OSSEOUS 
MEATUS  WITH  FISTULA  LEADING  INTO  SOME  POR- 
TION OF  THE  ADJOINING  TEMPORAL  BONE 

CARIES  and  fistula  are  sometimes  seen  in  the  auditory  canal  of  an 
individual  who  has  had  a  long-standing  suppuration  of  the  middle  ear 
and  subsequent  involvement  of  the  mastoid  cells,  which  latter  has 
resulted  in  the  death  of  some  portion  of  the  bony  structures  that  separate 
these  cells  from  the  posterior  segment  of  the  auditory  meatus.  A 
complete  description  of  the  condition  belongs,  therefore,  more  to  the 
chapter  on  Chronic  Mastoiditis  than  to  one  dealing  exclusively  with 
the  diseases  of  the  auditory  meatus.  Nevertheless,  the  importance 
of  this  condition  can  be  profitably  emphasized  by  a  brief  mention  at 
this  time. 

Violently  infective  aural  suppurations  of  the  acute  variety  are  some- 
times productive  of  osseous  necrosis  in  this  location,  but  whether  the 
result  of  acute  or  chronic  aural  suppuration,  the  leakage  of  pus  through 
the  carious  wall  of  the  antrum  or  mastoid  cells  in  the  direction  of  the 
meatus  at  once  sets  up  an  inflammation  of  the  periosteal  covering  of 
the  bone  with  accompanying  pain  and  tumefaction  in  the  auditory 
canal  (Fig.  74).  The  abscess  thus  formed  quickly  ruptures  into  the 
meatus,  leaving  a  fistula,  one  end  of  which  lies  deeply  in  the  mastoid 
portion  of  the  temporal  bone,  the  other  in  the  external  auditory  canal. 
The  presence  of  this  fistula  constitutes  one  of  the  diagnostic  points  in 
chionic  mastoiditis,  and  it  may  always  be  considered  as  pathognomonic 
of  an  advanced  state  of  that  disease  (see  p.  373). 

A  discharge  of  bloody  pus  from  the  meatus  takes  place  at  the  time 
of  the  rupture  of  the  abscess  into  the  canal,  and  this,  together  with  the 
relief  of  pain  that  then  occurs,  may  lead  the  physician  who  still  clings  to 
empiricism  in  the  practise  of  otology  to  the  belief  that  any  danger  that 
may  have  been  present  is  now  passed  and  that  recovery  will  quickly 
ensue.  Every  fact  connected  with  the  pathology  of  these  cases  dis- 
proves the  foundation  for  such  a  belief,  and  whereas  the  patient  will 
be  temporarily  improved  by  the  rupture  of  the  abscess  and  the  discharge 
of  pus  into  the  canal,  very  soon  polypi  will  spring  out  from  the  mouth  of 

157 


158  THE   PRINCIPLES   AND   PRACTICE   OF  OTOLOGY 

the  fistula  and  these  will  in  time  fill  the  meatus  and  obstruct  the  drainage 
both  from  the  fistula  and  the  suppurating  middle  ear.  As  a  conse- 
quence the  retained  pus  becomes  foul  smelling  and  irritant,  the  meatal 
walls  are  excoriated,  and  the  glands  of  the  neck  are  sometimes  infected 
and  swollen.  Intracranial  complication  is  not  an  uncommon  occurrence 
in  these  neglected  cases. 

The  presence  of  a  fistula  in  the  posterior  wall  of  the  auditory  meatus, 
which  leads  to  sequestra  or  necrosis  in  the  mastoid  structures,  should, 
therefore,  be  regarded  as  among  the  gravest  of  otologic  occurrences, 
because  it  has  become  a  common  experience  with  operators  of  large 
opportunity  for  observation  to  find,  on  opening  the  mastoid  antrum 
and  tip  of  the  mastoid  process  in  such  cases,  that  the  osseous  necrosis 
has  been  extensive,  involving  all  the  cellular  structures  of  this  region, 
and  not  infrequently  laying  bare  the  dura  mater  over  the  tegmen  antri, 
tegmen  tympani,  or  over  the  groove  containing  the  lateral  sinus.  It 
is  in  this  class  of  cases  that  brain  abscess,  localized  or  general  meningitis, 
or  sinus  infection  with  thrombosis  most  frequently  takes  place,  and 
no  doubt  can  be  entertained  concerning  the  belief  that  through  causes 
acting  as  here  stated  a  great  mortality  has  resulted  in  the  past  without 
the  attendant  realizing  the  connection  that  existed  between  the  aural 
affection  and  the  reported  death. 

Treatment. — The  treatment  is  essentially  surgical.  Poultices, 
powders,  and,  lotions  are  useless  and  consume  time  that  should  be 
employed  in  a  more  rational  practise.  If  the  case  is  a  mild  one,  and 
particularly  if  the  fistula  and  underlying  necrotic  area  are  found  in  any 
other  part  of  the  canal  except  that  which  lies  in  contact  with  the  mastoid 
cells — namely,  the  posterosuperior — the  ear  may  very  properly  be 
syringed,  the  granulations  and  polypi  be  snared  or  cureted  from  the 
canal  and  mouth  of  the  fistula,  and  an  effort  be  made  to  extract  any 
sequestrum  that  may  be  found  lying  loosely  in  the  channel,  with  the 
hope  that  the  entire  disease  may  in  this  way  be  reached  and  removed. 
Success,  however,  rarely  follows  these  trivial  measures  and  if  the  fistula 
enters  the  meatus  upon  its  posterosuperior  wall,  and  if  it  is  found  by 
probing  to  extend  in  the  direction  of  the  mastoid  cells  or  antrum,  either 
the  radical  mastoid  operation  or  the  operation  described  as  appropriate 
for  acute  mastoiditis  is,  beyond  question,  indicated  (see  Chapters  XXV. 
and  XXX.). 


CHAPTER  XVI 

OTHER   CONDITIONS   OF   THE   EXTERNAL    AUDITORY 
MEATUS  THAT  ARE  MORE  RARELY  ENCOUNTERED 

HEMORRHAGIC  EXTERNAL  OTITIS 

THIS  affection  consists  in  the  effusion  of  blood  under  the  epidermal 
layers  of  the  skin  of  the  auditory  meatus,  as  a  result  of  which  elongated, 
bluish-colored  blebs  appear  in  the  canal.  The  most  usual  site  of  the 
blebs  is  upon  the  inferior  and  posterior  walls,  and  Politzer  states  that 
the  bony  portion  of  the  meatus  only  is  involved.  The  tumefactions 
occasioned  by  these  hemorrhagic  effusions  may  extend  from  the  outer 
margin  of  the  osseous  meatus  inward  as  far  as  the  attachment  of  the 
drum  membrane,  and  small  vesicles  of  the  same  character  are  some- 
times seen  upon  the  membrane  itself. 

The  symptoms  depend  upon  the  extent  and  severity  of  the  vesicula- 
tion.  If  the  drum  membrane  is  involved  and  the  blisters  are  large 
enough  to  fill  the  auditory  canal,  more  or  less  deafness  and  tinnitus 
aurium  will  be  present.  A  moderate  deafness  and  some  pain  are 
complained  of  in  the  beginning,  but  these  disappear  at  once  when  the 
contained  fluid  is  evacuated  either  by  puncture  or  spontaneous  rupture 
of  the  vesicles. 

Politzer  states  that  the  affection  occurs  oftenest  in  young  persons 
and  in  those  suffering  from  an  otitis  media  due  to  influenza,  but  Bacon 
has  reported  cases  which  occurred  independently  of  any  middle-ear 
inflammation. 

The  diagnosis  can  be  readily  made  by  an  examination  of  the  deeper 
portion  of  the  auditory  canal,  where  one  or  more  blistered  surfaces 
will  be  seen  as  obstructive,  bluish  tumors.  When  these  are  touched 
with  a  probe  they  are  found  to  be  soft  and  to  contain  fluid  of  some  kind. 
To  make  certain  as  to  the  nature  of  its  contents  one  of  the  blebs  may 
be  incised  and  the  fluid  obtained  for  closer  inspection.  The  disease 
reaches  its  height  in  three  or  four  days  and  terminates  in  a  cure  spon- 
taneously within  two  weeks. 

Treatment. — Little  treatment  will  be  necessary  further  than  to 
cleanse  the  meatus  with  antiseptics,  to  dry  the  affected  areas  with  cotton 

159 


l6o  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

cylinders,  to  incise  each  bleb  freely,  to  mop  its  contents  away  with 
gauze  or  cotton,  and  then  to  complete  the  dressing  by  the  insufflation 
of  a  small  amount  of  powdered  boric  acid.  Daily  cleansing  and  the 
application  of  boric  acid  powder  to  the  canal  may  be  subsequently 
required  for  a  few  days  or  until  the  parts  have  returned  to  normal. 

SPONTANEOUS  HEMORRHAGE  FROM  THE  AUDITORY  MEATUS 

A  few  cases  of  free  hemorrhage  from  the  canal  have  been  reported.1 
In  these  cases  the  observers  could  assign  no  cause  whatever  for  the 
occurrence  of  the  bleeding,  and  all  state  that  the  most  careful  and 
repeated  examination  of  the  canal  failed  to  detect  the  presence  of  any 
wound  or  abrasion.  Most  instances  of  this  kind  have  occurred  in 
young  girls  of  a  nervous  or  hysteric  habit,  von  Stein,  however,  reported 
a  case  in  a  boy  thirteen  years  old.  The  fluid  discharged  from  the  ear 
is  never  pure  blood,  but  is  rather  of  a  serosanguineous  character  and 
in  some  cases  is  foul  smelling.  More  or  less  deafness  accompanies  the 
discharge.  The  flow  of  blood  was  not  a  vicarious  hemorrhage  and  a 
hemorrhagic  diathesis  could  not  be  made  out.  While  the  hemorrhage 
from  the  ears  was  sometimes  quite  free,  it  never  became  dangerous  and 
recovery  always  took  place.  Cases  of  spontaneous  bleeding  from  the 
auditory  canal  are  cited  rather  as  curiosities  than  otherwise  and  the 
diagnosis  is  the  only  point  about  which  the  physician  need  seriously 
concern  himself.  Therefore  in  every  instance  of  aural  hemorrhage 
the  inspection  of  the  meatus  should  be  thorough,  and  the  decision  as  to 
whether  or  not  a  diseased  condition,  is  present  or  whether  a  spontaneous 
hemorrhage  is  going  on  must  be  based  upon  the  facts  obtained  by  an 
actual  observation  of  the  parts  in  question.  Spontaneous  hemorrhage 
of  the  auditory  meatus  should  also  be  distinguished  from  that  which 
occurs  in  malingerers,  in  which  latter  the  individuals  themselves  injure 
the  canal,  or  put  into  the  auditory  meatus  blood,  or  other  fluid  resem- 
bling blood,  for  the  sole  purpose  of  deception. 

1  Goldstein,  in  the  American  Academy  of  Ophthalmology  and  Otolaryngology,  reports 
a  case  of  spontaneous  bilateral  hemorrhage  in  a  girl  aged  twenty-two.  The  case  was 
under  the  immediate  and  frequent  observation  of  the  doctor  for  more  than  one  year. 
During  this  time  the  serosanguineous  fluid  was  seen  several  times  to  well  up  from  the 
bottom  of  the  auditory  canal.  No  abrasion  of  the  skin  of  the  external  auditory  meatus 
was  ever  found.  Goldstein  believed  that  the  hemorrhage  occurred  through  the  sebaceous 
follicles  at  the  inner  end  of  the  auditory  canal.  Similar  cases  have  been  observed  by 
Wheelock,  Trans-Indiana  State  Medical  Society,  1901;  by  S.  von  Stein,  Zeitschrijt  /. 
Ohrenheilkunde,  1903;  by  Gradinego,  Archiv  f.  O.,  1889,  and  several  others. 


OTHER   CONDITIONS   OF   THE    EXTERNAL    AUDITORY   MEATUS        l6l 


SYPHILIS  OF  THE  AUDITORY  MEATUS 

The  occurrence  of  the  primary,  secondary,  and  tertiary  lesions  of 
syphilis  on  the  auricle  and  within  the  external  meatus  has  been  recorded. 
The  primary  ulcers  originate  from  the  contact  of  infected  towels  and 
from  the  caresses  or  bites  of  syphilitic  individuals.  Secondary  and 
tertiary  manifestations  are  usually  seen  in  connection  with  evidences 
of  syphilis  on  some  other  part  of  the  body  (Fig.  88).  In  the  auditory 
meatus  the  disease  most  often  manifests  itself  in  the  form  of  condylomata, 
which  are  seen  in  the  outer  portion  of  the  canal  as  grayish-red,  warty, 
or  polypoid-looking  excrescences.  Their  presence  gives  rise  to  irrita- 
tion, swelling,  and  fetid  discharge  from  the  canal,  and  when  large 
enough  to  fill  the  lumen  of  the  meatus,  to  impairment  of  hearing  and 


Granulating  ulcer  of  pre-  — 
auricular  region 


Granulating  base  of  ulcer 
Denuded  cartilage 


FIG.  88. — TERTIARY  SYPHILIS  OF  THE  PREAURICULAR  REGION,  CONCHA  AND  TRAGUS. 

tinnitus  aurium.  Pain  may  also  be  present  as  a  result  of  the  inflamma- 
tory swelling  or  from  the  ulceration  of  the  canal,  which  is  one  consequence 
of  the  presence  of  the  condylomata. 

A  primary  ulcer  of  the  auricle  or  meatus  might  easily  be  mistaken 
for  similar  lesions  of  an  entirely  different  character.  The  diagnosis 
must,  therefore,  necessarily  be  made  from  the  history  of  the  occurrence, 
from  the  appearance  of  the  lesions,  and,  in  short,  upon  the  same  points 
from  which  a  diagnosis  of  primary  syphilis  would  be  made  if  the  genital 
organs  instead  of  the  ear  were  the  seat  of  the  ulcer.  Condylomata 
may  be  mistaken  for  warts,  granulation  tissue,  or  polypi.  Their  struc- 
ture is  less  firm  than  that  of  warts  and  they  are  more  resisting  to  the 
probe  than  granulation  tissue.  Condylomata  have  also  a  paler  appear- 
11 


1 62  THE   PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 

ance  than  granulations,  and  their  bases  of  attachment  are  commonly 
much  nearer  to  the  concha  than  in  case  the  growths  are  polypi. 

Treatment. — The  administration  of  potassium  iodid  or  mercury  or 
of  the  two  combined,  according  to  the  stage  of  the  disease,  is  indicated 
in  all  cases  when  once  a  positive  diagnosis  of  the  specific  nature  of  the 
disease  is  made.  Increasingly  large  doses  of  these  remedies  should 
be  given  until  the  limit  of  tolerance  is  reached.  Locally  the  parts 
should  be  kept  antiseptic.  Condylomata  may  be  removed  by  cauter- 
ization with  chromic  acid  or  pure  silver  nitrate.  More  frequently, 
however,  clipping  them  off  with  delicate  curved  scissors  and  afterward 
cauterizing  the  base  of  each  will  be  found  more  expedient.  After  cleans- 
ing and  drying  the  auditory  meatus  any  moist  or  ulcerated  surface 
that  remains  after  the  removal  of  the  granulomata  is  often  quickly  healed 
by  the  application  of  calomel  powder.  Most  writers,  however,  prefer 
to  touch  the  ulcerated  areas  with  diluted  tincture  of  iodin,  repeating 
this  treatment  frequently  until  all  the  sores  are  healed. 

VICARIOUS  HEMORRHAGE  OF  THE  EARS 

This  sometimes  occurs  in  the  female  at  the  same  time  as  the  men- 
strual function  or  it  may  entirely  take  the  place  of  the  menstruation. 
The  diagnosis  should  be  easy,  particularly  after  the  first  attack,  when 
it  will  be  found  to  recur  each  month  or  at  least  with  a  degree  of  regularity 
that  can  be  connected  with  menstruation.  The  treatment  is  gyneco- 
logic, and  should  be  directed  to  the  reproductive  organs  and  the  sys- 
temic condition  of  the  individual  rather  than  to  the  ear. 

TRAUMATIC  HEMORRHAGE  FROM  THE  AUDITORY  CANAL 
As  the  result  of  either  direct  or  indirect  injury  to  the  cutaneous 
lining  of  the  external  meatus,  to  the  deeper  osseous  structure  of  the 
temporal  bone,  or  to  the  middle  ear  or  labyrinth,  severe  or  even  fatal 
hemorrhage  may  occur  from  the  auditory  canal.  These  injuries  result 
from  knife  or  bullet  wounds,  from  the  forcible  entrance  into  the  ear 
of  any  foreign  body,  and  from  fractures  of  the  base  of  the  skull  which 
involve  the  petrous  portion  of  the  temporal.  The  entrance  of  corrosive 
chemicals,  molten  metals,  or  of  live  steam  into  the  ear  has  been  known 
to  result  in  deep  ulceration  which  lead  ultimately  to  a  fatal  hemorrhage. 
When  the  fracture  extends  into  the  cranial  cavity  through  the  mastoid 
antrum,  middle  ear,  or  external  auditory  canal  cerebrospinal  fluid  and 
blood  may  be  discharged  from  the  external  auditory  meatus  to  the 
amount  of  several  ounces  in  the  twenty-four  hours.  Since  these  injuries 
may  involve  the  entire  hearing  organ,  their  full  consideration  is  given 
under  the  heading  Injuries  to  the  Hearing  Apparatus. 


OTHER   CONDITIONS   OF   THE   EXTERNAL   AUDITORY   MEATUS        163 

EAR  COUGH 

While  ear  cough  can  scarcely  be  called  a  disease,  nevertheless  it 
is  a  symptom  which  is  so  often  met  with  while  examining  the  external 
auditory  meatus  that  its  occurrence  is  deserving  of  some  mention.  It 
is  not  an  uncommon  occurrence  to  find  an  individual  in  whom  a  dis- 
tressing or  even  violent  cough  is  brought  on  every  time  an  attempt  is 
made  to  introduce  the  aural  speculum  or  to  probe  or  otherwise  manipu- 
late the  instruments  in  the  canal  during  an  examination  or  treatment. 
This  cough  is  dry,  spasmodic,  and  often  continues  for  a  few  seconds 
after  withdrawing  from  the  ear  the  irritant  which  has  produced  it. 
The  presence  of  a  foreign  body,  hardened  ear-wax,  or  of  inflammatory 
swelling  of  the  canal  may  give  rise  to  a  dry  hacking  cough  which  may 
be  mistaken  as  a  symptom  of  serious  pulmonary  disease,  and  hence 
in  any  individual  whose  cough  is  of  this  character,  and  for  which  a 
definite  cause  is  not  elsewhere  discovered,  an  examination  of  the  auditory 
meatus  should  not  be  neglected. 


CHAPTER  XVII 

THE  METHODS  OF  THE  EXAMINATION  OF  THE 

PATIENT 

PREVIOUS  to  the  establishment  of  accurate  methods  for  the  examina- 
tion of  the  ear,  the  history  of  an  aural  disease  given  by  the  patient  was 
regarded  of  such  importance  that  upon  it  was  based  both  the  diagnosis 
and  the  subsequent  treatment.  While  at  present  the  tendency  in 
aural  practise  is  to  base  the  management  of  any  aural  ailment  largely 
upon  an  actual  inspection  and  recognition  of  the  pathologic  conditions 
which  are  present,  nevertheless  the  personal  history  of  each  case  is  of 
importance  and  should  by  no  means  be  ignored.  Such  a  history  should 
include  a  statement  of  any  hereditary  tendencies  toward  deafness,  tuber- 
culosis, syphilis,  or  catarrhal  disease,  and  of  all  the  serious  ailments 
from  which  the  patient  has  at  any  time  suffered,  especially  the  infective 
diseases  of  childhood,  meningitis,  and  typhoid  fever.  The  influence 
of  climatic  changes  upon  the  aural  affection,  the  amount  and  nature  of 
any  discharge  in  the  past  or  at  present,  the  presence  or  absence  of 
tinnitus  aurium,  and  the  degree  of  present  impairment  of  hearing,  are 
all  subjects  upon  which  the  patient  should  make  his  own  statement. 

THE  PHYSICAL  EXAMINATION 

The  successful  practise  of  modern  otology  must  depend  largely 
upon  the  acquisition  of  that  knowledge  concerning  each  individual 
case  which  can  only  be  acquired  by  the  most  painstaking  and  thorough 
physical  examination  of  the  diseased  ear.  Neither  a  reliable  diagnosis 
nor  prognosis  can  be  given  nor  a  rational  treatment  instituted  until  it  is 
definitely  known  what  particular  part  of  the  ear  is  affected,  and  what 
the  nature  and  extent  of  the  given  disease  may  be.  Inference  concerning 
the  character  of  aural  ailments  should  no  longer  receive  consideration 
in  the  practise  of  otology,  but  instead  definite  knowledge  must  be  ascer- 
tained by  the  employment  of  every  scientific  means  toward  the  discovery 
of  the  degree  and  nature  of  the  departure  from  the  normal.  The 
nieans  and  methods  of  conducting  such  an  examination  is,  therefore, 
given  here  somewhat  after  the  order  pursued  in  actual  practise. 

164 


THE    METHODS   OF   THE   EXAMINATION   OF   THE    PATIENT  165 

The  Light  and  Its  Employment. — A  good  light  is  a  first  essential 
to  a  satisfactory  aural  examination,  because  the  different  parts  of  the 
ear  which  are  to  be  examined  must  always  be  clearly  seen  and  sometimes 
manipulated  by  the  examiner  under  direct  illumination.  Sunlight, 
the  light  of  a  candle,  gas,  oil,  or  electricity  can  each  be  successfully 
employed,  but  it  is  obviously  best  to  become  accustomed  to  one  source 
of  light,  used  in  a  given  way  by  means  of  the  same  apparatus,  in  order 
to  be  the  better  able  to  judge  the  appearances  of  health  or  disease  under 
a  uniform  illumination  of  the  fundus  of  the  ear.  After  a  trial  of  the 
other  sources  of  light  in  common  usage  the  author  found  that  gas, 
used  in  the  Argand  burner  with  a  bull's  eye  condenser  (Fig.  92),  best 
served  his  purpose,  and  for  a  number  of  years  he  has  made  constant 
use  of  the  same  for  all  office  examinations  and  treatment.  During  the 
past  five  years  a  gas  mantel  has  been  used  on  this  lamp  with  the  greatest 
satisfaction. 

A  most  excellent  examining  light,  and  one  which  the  author  used 
exclusively  during  his  early  practise,  may  be  obtained  from  the  student's 
lamp.  When  this  lamp  is  used  the  bull's  eye  condenser  is  not  wholly 
satisfactory,  owing  to  the  added  difficulty  experienced  in  regulating  the 
flame.  The  employment  of  a  frosted  chimney  greatly  protects  the 
eyes  of  the  examiner  from  the  bright  rays  which,  if  not  thus  subdued, 
would  interfere  with  that  perfect  vision  essential  to  accurate  inspection. 

Electricity,  when  available,  is  convenient  and  second  in  choice. 
It  has  the  decided  advantage  of  not  producing  an  uncomfortably  high 
temperature  near  the  patient's  head.  It  may  be  used  in  a  condenser, 
in  which  a  32-  or  even  a  5o-candle  incandescent  lamp  is  placed.  An 
electric  lamp  consisting  of  only  the  conducting  cords  and  bulb  swung 
in  any  convenient  place  near  the  patient's  head  may  furnish  a  satis- 
factory source  of  light.  However  used,  some  provision  must  be  made 
to  cover  the  incandescent  wires  of  the  bulb,  since  otherwise  their  image 
will  often  be  reflected  across  the  field  under  examination  in  such  a  way 
as  to  greatly  interfere  with  exact  appearances  of  the  parts  undergoing 
the  examination.  To  obviate  this  occurrence  the  bulb  should  be 
frosted  or  the  lens  of  the  condenser  may  be  of  ground  glass. 

Sunlight  or  candle  light  are  oftener  used  from  necessity  rather  than 
from  choice.  A  candle  gives  an  illumination  too  weak  for  accurate 
inspection  and  should  be  employed  only  when  other  sources  of  light 
are  not  procurable.  On  the  other  hand,  sunlight,  if  softened  by  absorp- 
tion from  surrounding  bodies  to  an  extent  that  its  greatest  intensity  is 
lost,  becomes  an  admirable  medium  for  examining  the  depths  of  an 
ear.  The  objection  to  the  use  of  sunlight  is  that  all  conditions  neces- 


i66 


THE   PRINCIPLES    AND    PRACTICE    OF   OTOLOGY 


sary  to  its  use  are  seldom  such  that  it  can  be  depended  upon  for  the 
purpose  in  question. 

Since  aural  examinations  must  often  be  made  in  the  home  and 
with  the  patient  in  bed,  the  otologist  must  provide  a  source  of  light  for 

illumination  under  such  circum- 
stances. If  the  residence  is  sup- 
plied with  an  electric  current  the 
head  lamp  shown  in  Fig.  89  is 
preferred.  Such  an  instrument 
is  conveniently  carried  in  the  in- 
strument bag  and  during  its  use 
may  be  carried  to  any  required 
position  near  the  patient's  head — 
a  point  of  recommendation  when 
the  position  of  the  patient  must 
be  recumbent.  A  pocket  electric 
light  (Fig.  90)  can  be  used  for  the 
examination,  provided  it  has  a  lens 
which  will  properly  focus  the  rays 
upon  the  mirror  which  is  worn 
upon  the  forehead. 
An  examination  at  the  home  of  the  patient  may  also  be  made  by 
the  use  of  an  Argand,  a  student's,  or  other  oil  lamp;  but  when  either 
gas  or  oil  lamps  are  employed  for  the  illumination  it  becomes  necessary 
for  the  patient  to  sit  erect  in  bed  or,  preferably,  in  a  chair,  since  other- 
wise it  would  be  difficult  to  reflect  the  rays  of  light  to  the  depths  of  the  ear. 


FIG.  89. — KIRSTEIN'S  ELECTRIC  HEAD  LAMP. 


FIG.  go. — ELECTRIC  LIGHT,  CONVENIENT  TO  CARRY  IN  THE  BAG  FOR  MAKING  EXAMINATIONS  AT  THE  HOME. 

Whatever  source  of  light  is  selected,  it  is  necessary  to  employ  a 
proper  mirror  to  reflect  it  into  the  auditory  meatus.  Such  a  reflector  was 
formerly  held  in  the  hand,  but  since  this  required  the  use  of  one  of  the 


THE    METHODS  OF   THE    EXAMINATION    OF   THE    PATIENT  167 

operator's  hands  which  could  be  more  advantageously  employed  other- 
wise this  method  of  reflection  has  been  discarded  and  the  reflector  is 
now  either  worn  upon  the  examiner's  head  or  is  supported  from  an  arm 
at  an  exact  focussing  distance  from  both  the  light  and  patient.  The 
head-mirror  is  given  preference  chiefly  because  any  movement  of  the 
head  of  the  patient  can  be  immediately  followed  by  the  operator  without 
that  loss  of  time  which  would  be  required  for  readjustment  if  the  re- 
flector is  stationary;  hence  when  the  mirror  is  worn  on  the  head  the 
field  to  be  examined  can  be  constantly  illuminated  and  the  examination 
proceeds  without  interruption. 

Both  the  reflecting  mirror  and  the  head-band  should  be  carefully 
selected.     The  size  and  focussing  distance  of  the  mirror  are  of  great 


FIG.  91. — THE  HEAD  MIRROR  WITH  CELLULOID  HEAD-BAND  AND  PROPER  MOVABLE  JOINTS  OF  ATTACHMENT. 
Note  that  the  mirror  has  a  double  ball-and-socket  joint. 

importance.  A  mirror  with  a  diameter  of  3  inches  and  a  focussing 
distance  of  not  more  than  10  inches  is  preferable.  A  focussing  distance 
greater  than  10  inches  renders  the  illumination  indistinct  and  one  less 
than  10  inches  would  necessitate  such  close  proximity  of  patient  and 
examiner  as  to  interfere  with  the  necessary  manipulation  of  instruments 
in  the  ear.  A  head-band  of  celluloid  fits  more  accurately,  feels  more 
comfortable  on  the  head,  wears  longer,  and  is  more  sanitary  than  any 
other  (Fig.  91).  A  simple  ball-and-socket  joint  at  both  the  attachment 
to  band  and  mirror  are  all  that  can  be  desired.  The  nasal  and  forehead 
supports,  which  instrument-makers  sometimes  attach  to  the  head-band 
or  mirror,  are  a  hindrance  to  the  employment  of  the  reflector,  and  are, 
therefore,  objectionable  features. 


i68 


THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


The  light  to  be  used  is  placed  to  the  right  of  the  patient,  on  a  level 
with  the  ear  to  be  examined  and  a  short  distance  behind  it.  The  patient 
is  seated  in  a  chair  in  front  of  the  examiner,  who  is  also  seated.  Al- 
though a  good  examination  may  be  made  while  the  patient  occupies 
any  ordinary  straight-backed  chair,  yet  certain  features  in  the  con- 
struction of  the  chair  shown  in  Fig.  92,  which  has  been  made  as  a 
result  of  the  needs  of  the  otologist,  add  not  only  to  the  comfort  of  the 
patient  but  also  to  the  ease  with  which  the  examination  or  treatment 
is  conducted.  The  ideal  chair  has  a  seat  which  can  be  quickly  raised 
or  lowered  according  to  the  height  of  each  patient.  It  should  rest  so 


FIG.  92. — CONVENIENT  ARRANGEMENT  OF  FURNITURE  AND   INSTRUMENTS  FOR  OFFICE  EXAMINATION  AND 

TREATMENT. 

securely  upon  the  floor  that  no  tilting  motions  are  possible.  The  back 
should  be  straight  and  have  a  head-rest  which  will  enable  the  examiner 
to  change  the  position  of  the  patient's  head  frequently,  easily,  and 
without  discomfort  as  the  examination  progresses.  Should  giddiness 
suddenly  seize  the  patient  a  chair  that  may  be  quickly  tilted  to  the 
horizontal  is  both  convenient  and  useful.  The  chair  represented  in 
Fig.  92  combines  a  commendable  number  of  these  features. 

When  the  patient,  light,  head-mirror,  and  examiner  are  ready  as 
above  described,   the  external  auditory  meatus  should  be  examined 


THE    METHODS   OF   THE   EXAMINATION   OF   THE   PATIENT  169 

before  an  aural  speculum  has  been  introduced.  This  precaution  will 
prevent  overlooking  any  abnormality  or  disease  which  may  be  located 
in  that  portion  of  the  canal  which  is  commonly  covered  by  the  speculum 
when  the  latter  is  in  place.  Boils  of  the  auditory  canal  are  located 
just  within  the  meatus,  and  should  one  be  present,  it  will  not  only  be 
thus  concealed,  but  the  introduction  of  the  speculum  against  it  would 
give  rise  to  very  considerable  pain. 

To  accurately  reflect  light  from  a  head-mirror  into  a  narrow  cavity 
like  the  external  auditory  meatus  requires  much  practise.  Before  the 
student  of  otology  attempts  the  illumination  of  the  depths  of  the  ear 
he  will  do  well,  therefore,  previously  to  practise  its  reflection  into  the 
cavity  of  an  ear  model  (Fig.  39);  or,  if  such  a  model  is  not  accessible, 
a  valuable  experience  may  be  obtained  by  reflecting  the  light  upon  a 
spot  on  the  wall.  Persistent  practise  in  the  management  of  reflected 
light  will  prove  highly  profitable  to  the  student  or  physician  because 
the  art  of  its  employment  is  not  only  of  use  in  ear  examinations  but  also 
in  the  inspection  and  treatment  of  all  the  accessible  cavities  of  the 
body. 

Aural  Specula,  Their  Selection  and  Methods  of  Use. — The 
drum  membrane  lies  at  the  bottom  of  a  crooked  canal  and  at  a  depth 
of  about  i  \  inches.  It  is  only  in  exceptional  cases,  there- 
fore, that  the  examiner  is  able  to  see  this  structure  without 
the  aid  of  an  aural  speculum,  to  separate  the  walls  of  the 
auditory  meatus,  and  to  assist  in  straightening  the  canal. 
Aural  specula  are  constructed  of  silver,  vulcanite,  or 
aluminium.  The  two  former  materials  are  preferable, 
silver  being  given  choice,  first,  because  it  can  be  sterilized 
by  heat;  second,  from  this  material  the  speculum  walls 
can  be  made  very  thin,  thus  giving  the  instrument  the 
largest  possible  lumen,  a  feature  of  great  importance  in 
both  diagnosis  and  treatment,  since  the  larger  the  opening 
through  the  speculum  the  better  the  view  of  the  parts  to  be 
examined  (Fig.  93).  Hard-rubber  specula  may  be  steril- 
ized by  boiling,  provided  they  are  not  handled  with  suffi- 
cient force,  while  they  are  yet  hot,  to  distort  their  shape. 

Specula  are  constructed  with  either  a  cone  or  a  funnel  shape  and 
the  one  or  the  other  can  be  used  equally  well  according  to  individual 
preference  or  experience  of  the  examiner.  Since  the  shape  of  the 
external  auditory  meatus  is  somewhat  oval,  some  operators  prefer  a 
speculum  with  an  ovoid  instead  of  a  circular  contour.  During  an 
examination  of  the  fundus  of  the  ear  the  examiner  often  finds  it  desirable 


170 


THE   PRINCIPLES   AND    PRACTICE    OF   OTOLOGY 


to  rotate  the  speculum,  and  specula  of  circular  construction  are  ob- 
viously easier  of  rotation. 

The  length  of  the  aural  speculum  is  of  importance.  When  properly 
inserted  into  the  external  auditor}'  meatus  it  should  project  from  the 
concha  no  further  than  is  necessary  to  enable  the  operator  to  grasp  its 
outer  extremity  firmly  and  to  manipulate  it  with  that  perfect  ease  which 
should  characterize  every  step  of  an  aural  examination.  If  the  speculum 
is  too  long,  proper  illumination  of  the  deeper  portions  of  the  auditory 
canal  and  ease  of  instrumentation  within  the  ear  will  be  hindered. 

Retraction  of  the  Auricle.— Since  the  cartilaginous  and  bony 
meatus  join  each  other  at  an  angle  (Fig.  81),  it  becomes  essential  to 


FIG.  94. — METHOD  OF  RKTRACTIXG  THE  AURICLE  AND  OF  STRAIGHTENING  THF.  EXTERNAL  AUDITORY  MEATUS. 

Compare  the  direction  of  the  canal  shown  in  this  illustration  with  that  shown  in  Fig.  81,  in  which  the  external 

auditory  meatus  is  in  its  position  of  normal  repose. 

straighten  the  meatus  and  thus  to  render  the  two  portions  of  the  auditory 
canal  coincident  with  each  other  before  it  is  possible  to  illuminate  and 
inspect  the  fundus.  From  without  inward  the  auditory  canal  runs 
first  inward,  upward,  and  backward,  and  then  inward,  downward,  and 
forward.  To  efficiently  straighten  it,  therefore,  the  cartilaginous  or 
movable  part  must  be  lifted  upward,  backward,  and  outward.  The 
left  hand  of  the  operator  is  sufficient  to  manipulate  the  speculum, 
retract  the  auricle,  and  to  some  extent  support  .and  secure  the  desired 


THE    METHODS    OF   THE    EXAMINATION    OF   THE    PATIENT  171 

movements  of  the  patient's  head.  Fig.  94  shows  this  position  ready 
for  the  illumination  and  inspection  by  the  examiner,  who  now  properly 
focusses  the  light  upon  the  drum  membrane,  which  may  be  found 
normal  or  abnormal. 

The  Membrana  Tympani.— (a)  The  normal  drum-head  presents  a 
characteristic  and  rather  pleasing  appearance  (Fig.  95).  Its  oval 
contour,  irregular  surface,  and  its  color,  lights,  and  shadows  form  a 
picture  not  easily  mistaken  for  other  structures  after  once  having  been 
recognized.  Certain  landmarks  are  always  clearly  distinguishable 
upon  its  surface,  the  most  prominent  of  which  is  the  short  process  of 
the  malleus  (Fig.  96).  This  tiny  osseous  promontory  projects  outward 

Shrapnell's  membrane 

Posterior  fold 


Light  refle 


FIG.  95. — NORMAL  DRUM  MEM-  FIG.  96. — LANDMARKS  OF  NORMAL  DRUM  MEMBRANE. 

BRANE  AS  VIEWED  THROUGH  A  SPEC- 
ULUM  BY  REFLECTED  LIGHT.' 

• 

from  the  point  of  juncture  of  the  anterior  and  posterior  folds,  and  is 
cloaked  by  its  covering  of  tympanic  membrane.  Under  illumination 
the  rays  of  light  which  are  strongly  reflected  from  its  summit  give  an 
appearance  resembling  a  minute  ripe  pustule.  The  long  process  of 
the  malleus  extends  downward  and  backward  from  the  short  process, 

1  One  of  the  most  difficult  tasks  with  which  the  author  has  had  to  deal  in  the  prep- 
aration of  this  book  has  been  that  of  producing  a  satisfactory  representation  of  the  normal 
and  pathologic  drum  membrane,  as  seen  by  reflected  light  through  the  aural  speculum. 
A  comparison  of  the  illustrations  of  the  normal  drum  heads  that  are  given  in  the  several 
works  on  otology  will  show  a  considerable  variation  in  appearance.  No  doubt  this  differ- 
ence arises  from  two  reasons:  First,  the  high-class  artist,  who  alone  is  capable  of  repro- 
ducing the  appearance  of  the  drum  membrane  when  viewed  through  a  speculum,  is 
unfortunately  not  able  to  see  the  structures  intelligently  in  this  way,  and  hence  must 
depend  largely  upon  drawings  made  by  the  aurist.  Second,  the  picture  of  the  whole 
drum  head,  as  shown  above,  is  a  complete  one.  No  aurist  can  see  a  whole  drum  mem- 
brane at  any  one  instant,  and  hence  to  see  the  whole  he  must  place  the  patient's  head  in 
several  different  positions,  as  stated  in  the  text,  and  it  is  the  combination  of  these  several 
fragmentary  images  of  the  membrane  that  makes  up  the  whole,  as  shown  in  Fig.  95. 
Several  normal  membranes,  figured  in  various  text  books,  partake  largely  of  the  nature  of 
the  anatomic  membrane,  that  is  to  say,  they  look  much  as  the  membrane  would  if  all  the 
soft  parts  were  cut  away  and  the  tympanic  ring,  with  its  drum  membrane  attached,  were 
held  squarely  up  to  view.  Viewed  through  a  speculum,  however,  the  appearance  of  the 
structure  is  greatly  changed.  The  diameters  of  all  drum  membranes  shown  in  this 
work  are,  for  the  purpose  of  greater  clearness,  twice  enlarged. 


172  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

producing  the  appearance  of  a  ridge  across  the  membrane  as  far  as  its 
center,  at  which  point  the  process  curves  somewhat  forward  and  ends 
at  the  umbo  (Fig.  96).  From  the  umbo  a  light  reflex  begins,  widens 
as  it  extends  downward  and  forward  across  the  membrane,  and  at  its 
base  blends  with  the  deepening  shadow  of  the  surrounding  surface 
before  the  margin  of  the  tympanic  ring  is  reached.  This  cone  of  light 
is  caused  by  a  reflection  from  the  tympanic  membrane  and  its  total 
disappearance  or  alteration  from  the  normal  denotes  that  a  serious 
pathologic  change  of  some  kind  has  occurred  in  this  structure. 

The  anterior  and  posterior  folds  may  be  seen  to  extend,  the  one 
forward  and  upward  and  the  other  backward  and  upward,  from  the 
short  process  of  the  malleus  to  the  annulus  tympanicus.  The  posterior 
fold  is  most  clearly  seen,  and  because  of  its  situation  in  the  plane  much 
nearer  to  the  eye  of  the  observer  appears  to  be  the  longer  of  the  two. 
These  folds  separate  the  membrana  tensa  from  the  membrana  flaccida 
(Fig.  96). 

The  color  of  the  healthy  drum  membrane  varies  somewhat  with  the 
intensity  and  quality  of  the  light  used  for  its  illumination.  When 
illuminated  by  artificial  gas,  burned  in  a  lamp  provided  with  a  gas 
mantel  and  condenser,  the  membrane  has  a  pearl-gray  appearance  and 
a  lustre  entirely  peculiar  to  itself.  The  membrana  tympani  is  quite 
sensitive  to  the  manipulation  of  instruments  and  the  contact  of  fluids, 
and  hence  if  it  is  examined  immediately  after  syringing  the  auditory 
canal,  or  after  prolonged  retraction  of  the  auricle  and  repeated  insertion 
of  the  speculum,  there  will  probably  be  observed  a  blush  of  redness 
over  the  greater  part  and  a  deep  injection  of  the  vessels  running  parallel 
with  the  manubrium. 

(b)  The  Diseased  Tympanic  Membrane. — A  description  of  the 
pathologic  appearances  of  this  structure  which  characterize  its  diseases 
will  be  given  in  subsequent  chapters  devoted  to  the  inflammatory 
affections  of  the  middle  ear,  and  therefore  mention  of  them  will  be 
made  here  only  in  a  general  way.  In  all  examinations  of  the  fundus 
of  the  ear  the  landmarks  of  the  membrane  should,  if  present,  be  made 
out,  and  any  change  in  their  position  or  size  should  be  noted.  Absence 
of  these  landmarks  would  indicate  an  inflammatory  thickening  of  the 
drum-head  which  is  sufficient  to  obliterate  them.  The  light  reflex 
and  normal  color  are  the  first  to  disappear  during  an  inflammation,  and 
after  these  the  umbo,  manubrium,  and  short  process  usually  follow  in 
the  order  given.  The  short  process  may  often  be  distinguished  long 
after  the  others  have  been  submerged  by  the  inflammatory  changes. 
Likewise,  in  destructive  diseases  implicating  the  middle  ear,  this  process, 


THE   METHODS   OF   THE    EXAMINATION   OF   THE    PATIENT  173 

owing  to  its  abundant  blood-supply,  withstands  necrosis  better  than 
the  surrounding  tissues,  and  it  is  therefore  frequently  preserved  in  the 
midst  of  the  general  destruction  (Fig.  191).  Perforations  may  appear 
in  any  portion  of  the  membrane  and  may  be  of  any  size,  from  that  of  a 
pinhole  up  to  that  including  the  entire  drum-head  (see  Figs.  191,  194, 

P-  332). 

It  is  not  always  an  easy  matter  to  determine  the  presence,  size,  or 
location  of  a  perforation  in  the  membrana  tympani.  Assistance  in 
this  respect  may  be  obtained  if  during  the  inspection  of  the  fundus 
the  patient  should  employ  the  Valsalva  method  of  inflation,  which, 
by  forcing  bubbles  of  air  and  secretion  through  the  rupture,  will  thus 
designate  its  size  and  position.  Should  the  whole  drum  membrane  be 
wanting  this  fact  may  not  be  easy  of  verification.  However,  if  the 
membrane  is  entirely  destroyed,  the  fundus  will  usually  appear  more 
distant,  the  tympanic  mouth  of  the  Eustachian  tube  can  often  be  seen, 
and  a  probe  can  be  passed  into  it;  the  promontory  can  be  outlined  and 
the  niches  of  the  oval  and  round  windows  are  often  visible.  If  still  in 
doubt,  Siegle's  otoscope  (Fig.  97)  may  be  used  to  produce  suction  upon 
the  fundus,  during  which  the  observer  will  note  whether  or  not  there 
is  movement  of  any  part  of  the  suspected  drum  membrane.  If  absolutely 
no  movement  be  observed  at  the  site  of  the  drum  membrane  it  is  probable 
that  this  structure  is  not  present.  Adhesions  of  the  membrane  to  the 
promontory  or  other  portions  of  the  internal  tympanic  wall  are  also 
best  detected  by  the  use  of  Siegle's  otoscope.  This  instrument  should 
be  provided  with  a  suction-bulb  instead  of  a  mouth-piece  as  formerly. 
When  it  is  used  for  examination  purposes  the  air  is  partly  expelled  from 
the  bulb,  the  speculum  part  is  introduced,  air-tight,  into  the  external 
auditory  mcatus,  and  the  auricle  is  retracted  just  as  must  be  done  when 
the  examination  is  made  with  the  common  speculum.  When  the  fundus 
is  well  illuminated  and  the  observer  clearly  sees  every  part,  the  hand 
holding  the  air  bag  slowly  releases  the  compression,  when  suction  will 
at  once  be  made  upon  all  the  deeper  structures  of  the  auditory  canal. 
If  the  drum-head  is  normal  it  will  be  observed  to  move  perceptibly 
outward.  If  it  is  bound  by  adhesions  at  any  point  the  same  will  be 
shown  by  their  lack  of  mobility  during  suction,  while  the  adjacent 
membrane  can  be  moved  outward  and  inward  at  the  pleasure  of  the 
observer.  Siegle's  otoscope  should  be  used  neither  for  purposes  of 
examination  nor  treatment  except  under  good  illumination  and  the 
direction  of  the  eye  of  the  examiner,  who  should  see  every  movement 
of  the  drum  membrane  which  is  produced  by  the  manipulation  of  the 
instrument,  and  should  note  the  exact  effect  produced  by  the  suction 


174  THE    PRINCIPLES   AND    PRACTICE    OF   OTOLOGY 

upon  the  movable  parts.  If  this  care  in  the  use  of  Siegle's  otoscope  be 
not  observed,  atrophic  areas  in  the  drum  membrane  may  be  ruptured  by 
the  suction,  following  which,  unless  the  proper  precaution  be  taken,  an 
infection  and  consequent  suppuration  of  the  middle  ear  may  occur. 

Granulations  and  polypi  are  frequently  present  in  cases  of  chronic 
aural  discharge.  Polypi  may  be  small  and  occupy  only  the  cavity  of 
the  middle  ear  or  they  may  grow  through  the  perforation  into  the  audi- 
tory canal,  which  they  wholly  or  partially  fill,  and  in  neglected  cases 
may  become  large  enough  to  protrude  from  the  external  orifice  of  the 


FIG.  97. — SIEGLE'S  PNEUMATIC  OTOSCOPE. 

The  illustration  shows  the  bag  partly  compressed  preparatory  to  in- 
sertion of  the  speculum  dp,  and  outward  suction  upon  the  membrana 
tympani. 


FIG.  98. — AURAL  PROBE. 


auditory  meatus  (see  Fig.  201).  These  growths  appear  red  and  injected 
when  viewed  through  a  speculum  and  may  be  mistaken  for  an  inflamed 
and  swollen  drum  membrane.  They  bleed  easily  and  the  patient  often 
gives  a  history  of  bloody  discharges  from  the  ear  having  taken  place. 
Indeed,  the  alarm  commonly  produced  by  an  aural  hemorrhage  is  fre- 
quently the  sole  reason  for  the  patient  seeking  immediate  advice  concern- 
ing the  ailment.  A  delicate  aural  probe  (Fig.  98)  is  of  much  value  in 
determining  the  true  nature  of  many  pathologic  conditions  at  the  fundus 
of  the  ear,  concerning  which  impressions  formed  by  inspection  alone 


THE    METHODS    OF   THE    EXAMINATION   OF   THE    PATIENT 


175 


may  have  been  unreliable.  Polypi  or  other  growths  may  be  moved 
about  by  this  instrument  and  both  their  character  and  point  of  attach- 
ment may  thus  be  proved.  By  bending  it  to  any  required  angle,  the 
probe  can  be  passed  through  perforations  in  the  drum  membrane, 
and  necrotic  areas  in  otherwise  inaccessible  parts  of  the  drum  cavity 
may  by  this  means  be  positively  determined. 

In  uncomplicated  cases  of  labyrinthine  deafness,  of  deafness  due  to 
disease  of  the  auditory  nerve,  or  its  center  in  the  brain,  the  tympanic 
membrane  frequently  appears  unaltered  in  any  way  and  presents 
all  its  normal  characteristics. 

Impediments  to  the  Examination  of  the  External  Auditory 
Canal  and  of  the  Fundus  of  the  Ear. — (a)  In  elderly  persons  the 
walls  of  the  auditory  canal  are  often  so  relaxed  as  to  greatly  narrow  the 
lumen.  Narrowing  also  results  from  both  acute  and  chronic  inflamma- 
tion and  from  the  presence  of  osteoma  or  other  growths.  In  some 
individuals  the  channel  is  naturally  small  and 
the  drum  membrane  deeply  seated.  Abnormality 
from  any  cause  may  hinder  the  introduction  of 
the  speculum  or  prevent  the  passage  of  the  rays 
of  reflected  light  to  such  an  extent  as  to  render 
the  examination  impossible  or  incomplete.  Usu- 
ally, however,  it  is  possible  by  the  selection  of 
a  long,  narrow,  and  properly  constructed  spec- 
ulum (Fig.  99)  and  careful  retraction  of  the 
auricle  to  obtain  a  view  of  the  deeper  parts  that 
will  prove  at  least  fairly  satisfactory. 

(b)  In  some  persons,  usually  men  whose  bodies 
are  unduly  covered  with   hair,  a  growth   of  stiff 
hairs  is  found  in  the  outer  portion  of  the  audi- 
tory canal  which    is    sufficient    to    obstruct    the 
view  of  the  parts  beyond.     A  speculum  can  often 

be  selected  in  such  instances  which  will  efficiently  press  the  hairs  from 
view;  but  if  this  is  found  impossible  they  should  be  removed  by  means 
of  delicate  curved  scissors. 

(c)  Sometimes  cases  are  seen  in  which  the  introduction  of  an  aural 
speculum  gives  rise  to  such  severe  reflex  cough  as  to  render  the  examina- 
tion difficult.     A  thorough  inspection  under  such  circumstances  can 
only  be  made  when  the  greatest  possible  care  is  exercised  to  produce 
as  little  irritation  as  possible  from  the  use  of  the  examining  instruments. 

Determination  of  the  Patency  of  the  Eustachian  Tube  and 
the  Method  of  Inflation  of  the  Middle  Ear. — Preliminary  Exam- 


FIG.  99. — LONG  NARROW 
SPECULA  FOR  THE  EXAMINA- 
TION OF  THE  DEEPER  PARTS 
OF  THE  MEATUS  WHEN  THE 
LATTER  is  PARTIALLY  OB- 
STRUCTED BY  AN  INFLAMMA- 
TORY SWELLING  OR  GROWTH. 


i76 


THE   PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 


ination  of  the  Nose  and  Nasopharynx. — Before  the  steps  necessary 
for  either  an  efficient  examination  or  treatment  of  the  Eustachian  tube 
or  middle  ear  can  be  carried  out,  a  definite  knowledge  of  the  condition 
of  the  nose  and  nasopharynx  should  be  obtained.  While  it  is  entirely 


FIG.  ioo. — MYI.ES'  NASAL  SPECULUM. 

A  most  convenient  and  efficient  instrument  for  examining 

the  anterior  nasal  fossce.     Adult  size. 


FIG.  101. — MYLES'  NASAL  SPECULUM. 
Child's  size. 


beyond  the  province  of  this  work  to  describe  minutely  the  methods  of 
conducting- such  an  examination,  nevertheless  it  is  deemed  important  to 
emphasize  the  necessity  for  thoroughness  in  this  respect  and  to  briefly 
outline  the  necessary  course  to  be  pursued. 

Using  a  Myles  nasal  speculum  (Figs. 
TOO  and  101),  first  one  nostril  and  then  the 
other  is  dilated,  and  the  lumen  of  each 
nasal  meatus  is  carefully  inspected  to  de- 
termine the  presence  of  turgescences  or 
new  growths  of  the  turbinates  or  of 
spurs  or  deflections  of  the  nasal  septum. 
This  examination  will  be  much  facilitated 
if  there  is  sprayed  into  the  nostrils  a  4 
per  cent,  solution  of  cocain,  which  is  fol- 
lowed shortly  by  a  spray  of  the  solution 
of  adrenalin  chlorid.  Further  application 
of  a  stronger  solution  of  cocain  may,  if 
thought  necessary,  be  made  to  the  lower 
turbinate  by  means  of  a  cotton-tipped  applicator,  which  instrument 
should  at  the  same  time  be  employed  for  the  purpose  of  further  deter- 
mining the  size  and  nature  of  any  hypertrophy  or  spur  that  may  be 
present.  In  case  of  very  small  children  or  a  narrow  vestibule,  the 
small  size  of  Bosworth's  speculum  is  most  serviceable  (Fig.  102). 


FIG.  102. — BOSWORTH'S  SPECULUM. 
Convenient  for  very  small  children. 


THE    METHODS   OF  THE    EXAMINATION  OF   THE   PATIENT  177 

After  a  few  minutes  the  nasal  tissues  will  have  been  so  shrunken 
that  the  lower  meatus  will  be  opened  to  its  fullest  extent,  and  through 
it  the  examiner  will  often  be  able  to  determine  much  concerning  the 
condition  of  both  the  nose  and  nasopharynx.  In  this  way  the  experi- 
enced examiner  will  often  be  able  to  make  out  the  presence  of  an  adenoid 
which,  on  account  of  a  sensitive  throat,  he  is  unable  to  see  by  means  of 
the  postnasal  mirror.  Collections  of  ropy  mucus  or  dried  crusts  will 
also  be  seen  if  present,  whether  in  the  nose  or  in  the  nasopharynx. 

The  condition  of  the  mouth  and  teeth  should  next  receive  a  careful 
inspection.  Syphilitic  ulcers,  either  secondary  or  tertiary,  may  be 
found  in  the  mouth,  while  the  teeth  by  their  peculiar  setting  and  charac- 
teristic shape  may  indicate  the  inheritance  of  the  disease  (Fig.  303). 
The  presence  of  healed  cicatrices  are  most  usually  indicative  of  a  pre- 
vious syphilis  and  may  account  for  an  otherwise  inexplicable  aural 
affection.  The  discovery  of  a  decayed  tooth  or  an  ulcerated  gum  may 
account  for  an  earache  that  is  complained  of,  and  therefore  in  any  case 
of  otalgia  in  which  the  drum  membrane  is  found  on  examination  to  be 
normal,  an  explanation  for  this  pain  should  at  once  be  sought  for 
in  an  exposed  dental  nerve.  Ulceration  of  the  throat,  especially  if 
implicating  the  tissues  of  the  epiglottis,  tonsil,  or  lateral  pharyngeal 
wall,  may  also  reflexly  give  rise  to  an  otalgia.  Much  importance  must 
be  attached  to  the  influence  of  the  faucial  and  nasopharyngeal  tonsils 
in  the  causation  of  aural  diseases,  and  hence  an  examination  of  these 
structures  should  not  be  overlooked.  This  subject  is  considered  of 
sufficient  importance  to  merit  a  separate  chapter  for  its  consideration 
(see  Chapter  XX). 

Crusts  of  dried  secretion,  such  as  are  present  in  the  nose  and  naso- 
pharynx of  those  afflicted  by  atrophic  rhinitis  or  ozena,  must  be  removed 
before  attempts  are  made  to  pass  the  Eustachian  catheter.  Likewise 
the  thick  ropy  mucus  which  is  often  present  as  a  result  of  acute  or 
chronic  disease  must  be  cleared  away  by  the  postnasal  syringe  or  atom- 
izer (Fig.  103),  since  if  this  be  allowed  to  remain  it  will  block  the  orifices 
of  the  Eustachian  tubes  to  such  an  extent  as  to  greatly  hinder  or  entirely 
prevent  the  passage  of  the  air  through  the  catheter,  even  when  the 
latter  has  been  properly  placed  in  the  mouth  of  the  Eustachian  tube. 
There  is  also  a  probability  of  blowing  some  of  the  foul  nasopharyngeal 
secretion  into  the  middle  ear  and  of  inciting  an  acute  otitis  media, 
should  it  not  have  been  thoroughly  removed  before  the  Politzer  or 
catheter  inflation  is  performed. 

It  has  already  been  shown  in  the  chapter  devoted  to  the  physiology 
of  the  hearing  apparatus  that  the  Eustachian  tube  has  a  function  most 
12 


i78 


THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


essential  to  normal  hearing.  Any  acute  or  prolonged  disturbance  of 
this  function  will  not  only  impair  the  hearing  but  will  also  lead  to  patho- 
logic changes  in  both  the  tube  and  tympanic  cavity  of  an  exudative,  sup- 
purative,  or  proliferative  nature.  An  examination  as  to  the  condition 
of  this  tube  must,  therefore,  be  considered  an  important  part  of  the 
aural  investigation.  There  are  three  methods  of  determining  the 
patency  of  the  tube  and  at  the  same  time  of  inflating  the  tympanic  cavity : 
(a)  The  Valsalva  method,  which  dates  back  to  the  sixteenth  century. 
It  is  performed  by  the  individual  himself,  who  first  takes  a  deep  inhala- 
tion, closes  the  mouth  tightly,  obstructs  both  nostrils  completely  by 
compressing  the  nasal  alas  between  the  thumb  and  forefinger,  and  then 
makes  forcible  effort  to  blow  the  obstructed  nose.  The  air  meets  with 
resistance  at  every  outlet  except  the  Eustachian  tube,  into  which  it 


FIG.  103. — SET  OF  DE  VILBISS'  ATOMIZERS. 

enters  with  a  force  determined  by  the  resistance  within  the  tube,  and 
by  the  power  with  which  the  air-current  is  driven  against  it.  Inflation 
through  the  principles  involved  in  this  method  is  frequently,  though 
unintentionally,  accomplished  during  the  progress  of  head  colds,  when 
the  nostrils  are  so  much  obstructed  that  great  effort  is  required  to  blow 
and  cleanse  them  and  air  is,  as  a  consequence,  forced  into  the  middle 
ear.  Inflation  under  these  circumstances  is  thus  so  frequently  per- 
formed during  a  severe  rhinitis  that  the  patient  may  as  a  result  complain 
greatly  of  fulness,  discomfort,  or  pain  in  the  ear.  Disease  germs  are 
also  at  times  transported  to  the  tympanum  in  this  way,  where  they 
become  the  exciting  cause  of  inflammatory  or  suppurative  affections 
of  this  cavity.  As  a  means  of  treatment  the  Valsalva  method  is  not 
often  to  be  recommended,  since  the  patient  is  apt  to  employ  it  to  an. 


THE    METHODS    OF   THE    EXAMINATION    OF  THE    PATIENT  179 

excess  that  is  productive  of  middle-ear  congestion  or  relaxation  of  the 
tympanic  membrane.  As  an  aid  to  diagnosis  it  is  sometimes  of  use. 
During  an  examination  of  the  drum  membrane  it  is,  as  previously 
stated,  often  difficult  to  recognize  a  small  perforation.  If  Valsalva 
inflation  is  performed  by  the  patient  while  the  fundus  is  illuminated, 
and  there  is  a  rupture  present  in  the  drum  membrane,  its  situation 
will  usually  be  demonstrated  by  the  escape  of  air,  together  with  any 
secretion  that  may  have  accumulated  within  the  middle  ear. 

(6)  The  Polltzer  method  was  devised  by  Prof.  Politzer,  of  Vienna, 
in  1863.  It  consists  in  driving  the  blast  of  air  through  one  nostril  at 
the  moment  when  all  the  exits  to  the  nasopharynx  except  the  Eustachian 
tubes  are  closed.  The  Politzer  air-bag,  a  short  piece  of  connecting 
rubber  tube,  and  a  bluntly  conic  hard -rubber  or  metal  nasal  tip  con- 
stitute the  only  outfit  necessary  to  its  performance  (Fig.  104).  An 
air-bag  should  be  selected  of  such  size  as  can  be  readily  grasped  by 
the  operator's  hand.  Hence,  each  operator  may  most  conveniently 
use  a  different  sized  bag.  The  caliber  of  both  connecting  tube  and 
nasal  tip  should  be  ample  to  transmit  the  full  blast  of  air  from  the  bag. 
If  the  latter  is  to  be  used  only  for  purposes  of  Politzer  inflation,  it  is 
not  necessary  that  it  be  constructed  with  an  intake  air-valve.  However, 
it  is  often  desirable  to  use  the  bag  in  connection  with  the  Eustachian 
catheter  inflation,  and  when  so  used  an  air-valve  is  of  the  greatest 
convenience,  since  it  avoids  the  necessity  of  removing  the  nozzle  from 
the  mouth  of  the  catheter  after  each  compression  of  the  bag. 

Technic  o]  Politzer  ization. — The  patient  .should  usually  be  seated. 
He  is  given  a  small  sip  of  water  and  requested  to  hold  it  in  the  mouth 
until  told  to  swallow.  While  stating  this  request,  the  operator  inserts 
the  conic  tip  of  the  Politzer  air-bag  into  the  vestibule  of  one  nostril  so 
that  it  fits  tightly  and  blocks  the  opening.  The  wing  of  the  opposite 
nostril  is  compressed  against  the  adjacent  nasal  septum  with  sufficient 
firmness  to  occlude  the  passage.  The  patient  is  then  told  to  swallow, 
coincident  with  the  performance  of  which  act  compression  of  the  bag 
is  quickly  made. 

Inflation  of  the  middle  ear  will  usually  result  from  the  above  pro- 
cedure provided  the  technic  has  been  followed  and  the  patient  has  given 
efficient  cooperation.  Failure  will  result,  first,  if  the  Eustachian  tube 
is  greatly  obstructed  by  mucus,  swelling,  or  stricture;  second,  if  the 
conic  tip  fits  the  nostril  imperfectly,  or  if  complete  occlusion  of  the 
opposite  nostril  has  not  been  effected;  third,  if  the  patient  fails  entirely 
to  obey  the  command  to  swallow,  or  if  the  operator  fails  to  recognize 
the  fact  that  swallowing  is  taking  place,  and  hence  empties  the  air-bag 


i8o 


THE   PRINCIPLES    AND    PRACTICE   OF   OTOLOGY 


either  too  soon  or  too  late.  Failure  from  any  of  the  latter  causes  is  due 
to  the  fact  that  the  nasopharynx  has  not  been  shut  off  from  the  space 
below,  and  hence  the  blast  from  the  bag  enters  the  stomach  or  blows 
the  water  from  the  patient's  mouth.  A  good  rule  is  to  watch  the  patient's 
"Adam's  apple"  at  the  instant  the  command  is  given  the  patient  to 
swallow,  and  when  .this  prominence  of  the  larynx  begins  to  rise,  this 
fact  is  evidence  that  the  act  of  swallowing  is  in  progress,  and  that  the 
proper  time  has  arrived  to  perform  the  inflation. 

In  actual  practise,  certain  modifications  of  the  Politzer  method  are 
often  found  necessary.     Children  will  seldom  cooperate  satisfactorily, 


FIG.   104. —  MODIFIED  POLITZERIZATION. 

The  patient  inhales  deeply  and  then  forcibly  blows  between  the  partly  closed  lips  while  the  operator  performs 
the  inflation  in  the  usual  manner. 

and  hence  his  method  will,  in  this  class  of  patients,  prove  a  failure. 
Almost  every  child,  however,  can  be  induced  to  blow  out  his  cheeks 
with  sufficient  force  to  make  an  effective  opposing  current  to  the  one 
driven  from  the  air-bag,  and  the  two,  meeting  in  the  nasopharynx,  will 
satisfactorily  open  the  Eustachian  tube  and  produce  the  desired  effect 
(Fig.  104).  Merely  puffing  out  the  cheeks,  by  using  the  air  already  in 
the  mouth,  is  not  sufficient  cooperation  on  the  part  of  the  patient,  because 
the  procedure  furnishes  no  counter-current  in  the  fauces.  The  child 
must,  therefore,  be  shown  how  to  perform  by  first  filling  his  lungs  by  a 
deep  inhalation  and  afterward  forcibly  blowing  out  between  the  partly 
compressed  lips,  just  as  he  would  do  in  blowing  a  blast  from  a  horn. 


THE    METHODS  OF   THE    EXAMINATION   OF  THE   PATIENT  l8l 

If  this  plan  is  not  comprehended  by  the  child  he  may  be  given  a 
mouthpiece,  through  which  is  a  small  opening,  and  told  to  blow 
vigorously  through  the  same.  When  the  child  is  observed  to  blow 
with  sufficient  energy,  the  tip  of  the  air-bag  is  inserted  into  the  nostril 
and  the  inflation  can  be  successfully  performed  (Fig.  104).  No  difficulty 
should  be  experienced  in  inflating  the  middle  ear  of  infants,  because 
the  act  of  crying  shuts  off  the  nasopharyngeal  space  quite  as  efficiently 
as  any  of  the  artificial  methods  just  described.  Hence,  during  the 
height  of  the  expiratory  cry  the  nasal  tip  is  inserted,  the  opposite  nostril 
occluded,  and  the  inflation  gently  performed.  Moreover,  in  infants 
and  young  children  the  Eustachian  tube  is  proportionately  shorter  and 
wider  than  in  the  adult,  and  for  this  reason  inflation  is  correspondingly 
easier. 

As  a  therapeutic  measure,  Politzerization  holds  a  middle  position 
between  the  Valsalva  method  and  inflation  by  means  of  the  catheter. 
In  children  it  is  the  only  satisfactory  means  of  restoring  the  normal 
air  pressure  in  the  tympanum,  since  before  the  age  of  ten  it  is  seldom 
possible  or  desirable  to  use  the  catheter  for  this  purpose.  In  cases 
where  nasal  obstruction  is  present  or  in  which  the  mucous  lining  is  hyper- 
sensitive, and  in  patients  who  are  apprehensive  concerning  the  use  of 
instruments  through  the  nose,  Politzerization  often  becomes  the  method 
of  choice. 

(c)  Catheter ization  oj  the  Eustachian  Tube. — In  adults  and  in  all 
cases  where  there  is  no  nasal  obstruction  present  which  prevents  its 
use,  the  Eustachian  catheter  should  be  employed  in  preference  to  either 
of  the  preceding  methods,  since  by  its  employment  a  much  greater 
precision  in  diagnosis  and  treatment  is  possible. 

In  cases  where  only  one  ear  is  diseased,  it  is  clearly  evident  -that 
none  but  the  affected  organ  should  be  inflated,  and  that  this  desired 
end  can  only  be  attained  by  the  use  of  the  catheter.  When  the  Eus- 
tachian catheter  is  employed  the  operator  is  able  to  accurately  measure 
the  degree  of  force  of  the  air  current  he  is  using — a  matter  of  the  greatest 
importance  when  it  is  remembered  that  this  force  should  vary  according 
to  the  amount  of  obstruction  to  be  overcome  in  the  Eustachian  tube 
and  to  the  amount  of  resistance  offered  by  the  drum  membrane  to  its 
replacement.  When  this  membrane  is  found  on  examination  to  be 
atrophic  or  thin  at  any  point,  even  a  moderate  force  employed  during 
the  inflation  might  cause  a  rupture.  On  the  other  hand,  if  the  mem- 
brane is  thickened  and  bound  in  an  abnormal  position  by  adhesions, 
a  pressure  of  30  or  40  pounds  may  be  used  without  any  perceptible 
outer  movement  of  the  drum-head  or  without  running  the  slightest 


1 82  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

risk  of  its  rupture.  Hence,  when  provided  with  compressed  air,  which 
is  governed  by  a  pressure-regulator,  the  physician  is  enabled  by  the 
use  of  a  catheter  to  employ  that  exact  amount  of  force  during  the  infla- 
tion which  the  preceding  examination  of  the  drum  membrane  may 
have  shown  to  be  indicated. 

Eustachian  catheterization  is  not  resorted  to  as  a  means  of  diag- 
nosis and  treatment  as  often  as  its  importance  would  indicate.  This  is 
partly  due  to  the  slightly  greater  time  required,  but  more  largely,  perhaps, 
because  of  the  skill  necessary  to  its  successful  and  painless  performance. 
Armed  with  a  definite  knowledge  of  the  anatomy  of  the  nose  and  naso- 
pharynx and  a  proper  amount  of  training  in  the  steps  necessary  to  its 
passage,  the  physician  should  be  able  to  successfully  introduce  the 
catheter  easily,  quickly,  and  painlessly  in  any  case  in  which  the  nasal 


FIG.  105. — PERPENDICULAR  SECTION  THROUGH  NOSE  SHOWING  ONE  OF  THE  DIFFICULTIES  IN  EUSTACHIAN 

CATHETERIZATION. 

The  catheter  with  an  arc  of  A  C  could  not  pass  through  the  inferior  meatus  the  width  of  which  is  B  C. 
In  many  cases  like  this  the  catheter  may  be  easily  inserted  by  turning  the  concavity  of  the  instrument  upward 
and  causing  the  beak  to  hook  under  the  deflection  until  the  deformity  is  passed,  when  the  guide  is  turned  into 
the  usual  downward  position. 

passages  are  not  obstructed.  Bleeding  from  the  nose  or  severe  pain 
occurring  as  a  result  of  Eustachian  catheterization  is  evidence  either  of 
the  employment  of  unnecessary  force  or  of  faulty  technic,  and  should  be 
considered  an  inexcusable  occurrence.  Catheterization  must  be  regarded 
as  a  procedure  requiring  only  the  most  gentle  and  painless  manipulation 
for  its  performance,  and  it  can  therefore  in  no  sense  be  classed  as  an 
operation.  Before  attempting  to  introduce  the  catheter  for  the  first  time 
the  nostrils  should  be  examined  by  means  of  reflected  light  in  order  to  de- 
termine whether  or  not  they  contain  new  growths  or  deformities  to  such 
an  extent  as  to  interfere  with  or  entirely  prevent  the  introduction  of  the 
instrument.  If,  as  frequently  happens  at  this  examination,  the  patient 
is  unduly  apprehensive  concerning  the  procedure,  it  is  wise  to  spray  a 


THE    METHODS    OF   THE    EXAMINATION    OF   THE    PATIENT  183 

2  per  cent,  solution  of  cocain  into  the  nostril  and  allow  a  few  minutes 
to  elapse  before  attempting  to  introduce  the  catheter.  In  case  the 
nostrils  are  narrow  or  the  turbinates  are  sufficiently  turgescent  to  fill 
the  spaces  the  addition  of  a  solution  of  adrenalin  chlorid  to  the  cocain 
mixture  will  provide  additional  room  in  the  nose,  and  will  thus  greatly 
facilitate  the  ease  of  the  performance.  Should  the  nasal  septum  be 
greatly  deflected  to  one  side  or  a  spur  so  project  across  the  nasal  space 
as  to  obstruct  the  lower  meatus  (Fig.  105),  it  is  often  difficult  or  even 


FIG.  106. — EUSTACHIAN  CATHETERS. 
Different-sized  catheters  from  which  a  selection  can  be  made  to  fit  almost  any  case. 

impossible  to  pass  the  Eustachian  catheter.  Hypertrophies  or  new 
growths  which  are  large  enough  to  partially  or  completely  block  the 
nasal  passage  may  likewise  render  the  procedure  impossible.  The  cath- 
eter may  frequently  be  passed  through  a  nostril  which  is  much  occluded 
by  a  spur  or  hypertrophy,  should  the  instrument  be  introduced  in  a 
position  the  reverse  to  that  normally  employed,  or  should  the  operator 
allow  it  to  follow  a  corkscrew  course  through  the  inferior  meatus. 


184  THE    PRINCIPLES   AND    PRACTICE    OF   OTOLOGY 

At  least  three  catheters  of  different  sizes  are  necessary  and  a  full 
assortment  representing  many  sizes  and  shapes  are  advantageous 
(Fig.  106).  Each  should  be  so  constructed  that  the  largest  lumen  is 
provided  that  is  consistent  with  the  required  strength  of  the  instrument. 
The  nasopharyngeal  end,  or  beak,  must  have  the  edges  of  its  circum- 
ference so  beveled  and  smoothed  that  no  injury  can  be  inflicted  on  the 
tubal  orifice  or  its  adjacent  parts.  The  proximal  or  funnel  end  (Fig.  106, 
a)  is  provided  with  an  elliptic  ring  (Fig.  106,  b},  called  the  guide,  which 
is  attached  in  such  manner  that  it  always  points  in  the  same  direction 
as  the  beak,  a  device  whereby  the  operator  may  know,  at  any  time  during 
the  insertion  of  the  catheter,  the  exact  angle  at  which  the  beak  may  be 
directed.  This  guide  is  of  particular  service,  as  will  be  presently  seen, 
in  indicating  the  proper  position  of  the  catheter  when  it  has  been  finally 
turned  into  the  tubal  orifice.  Eustachian  catheters  are  usually  made 
from  pure  coin  or  German  silver  or  from  hard  rubber.  Catheters  con- 
structed from  pure  silver  are  best  because  of  the  ease  with  which  they 
may  be  bent  into  any  desired  shape.  A  stock  instrument,  constructed 
of  inflexible  material  and  with  a  standard  curve  at  its  distal  or  naso- 
pharyngeal end,  could  not  be  successfully  introduced  in  every  case,  for 
the  reason  that  the  normal  width  of  the  nasopharynx  of  each  individual 
varies  greatly,  and  therefore  a  different  length  of  the  arc-end  of  the 
catheter  will  be  required  to  meet  this  variation.  Hence,  it  often  becomes 
necessary  for  the  operator  to  change  both  the  length  of  the  arc  and 
the  degree  of  the  curve  before  he  will  be  able  to  successfully  introduce 
the  catheter. 

Catheters  are  found  in  the  shops  varying  in  length  from  5!  to  7^ 
inches.  One  of  6J  inches  will  be  most  satisfactory  in  the  great  majority 
of  cases.  When  the  instrument  is  properly  introduced  its  proximal 
or  funnel  end  should  project  but  little  beyond  the  tip  of  the  patient's 
nose,  for  if  it  protrude  2  or  3  inches,  as  will  be  the  case  if  the  longest 
catheter  has  been  selected,  the  projecting  part  becomes  a  lever  of  such 
length  that  even  the  delicate  manipulations  necessary  to  perform  the 
inflation  will  produce  a  powerful  movement  of  the  beak  within  the 
tubal  orifice,  and  consequent  discomfort  or  pain  to  the  patient. 

The  patient's  full  confidence  and  cooperation  should  always  be 
obtained  if  possible,  and  he  should  be  requested  not  to  squint  the  eyes, 
make  facial  grimaces,  nor  swallow  during  the  few  seconds  required 
for  the  introduction  of  the  instrument,  for  as  will  be  presently  seen, 
under  technic  of  catheterization,  any  such  muscular  movement  at 
this  time  will  not  only  cause  the  patient  pain  but  may  also  defeat  the 
purpose  in  view.  Having  obtained  a  knowledge  of  the  condition 


THE    METHODS    OF    THE    EXAMINATION   OF   THE    PATIENT  185 

within  the  nose,  and  having  secured  the  patient's  confidence  by  assurance 
that  the  performance  is  a  painless  one,  all  is  ready  to  proceed  with 
the  introduction  of  the  instrument. 

Technic  oj  Eustachian  Catheter ization. — (a]  First  Method. — Both 
patient  and  operator  are  seated  facing  each  other.  If  the  nasal  pas- 
sages have  been  found  to  be  fairly  normal,  reflected  light  is  not  needed 
during  any  period  of  the  catheterization.  With  the  patient  erect  and 
his  head  slightly  inclined  forward,  the  fingers  of  the  left  hand  of  the 
operator  rest  gently  against  the  nose  and  lower  forehead,  for  the  purpose 
of  supporting  the  head  and  at  the  same  time  securing  any  desired  change 


FIG.  107. — POSITION  OF  THE  EUSTACHIAN  CATHETER  DURING  THE  FIRST  STEP  OF  ITS  INTRODUCTION. 
The  tip  of  the  patient's  nose  should  be  slightly  elevated  by  the  thumb  of  left  hand  of  the  operator  during  this 

step. 

of  position.-  The  thumb  of  the  same  hand  slightly  elevates  the  nasal 
tip.  The  catheter  is  taken  lightly  between  the  thumb  and  first  two 
fingers  of  the  right  hand  and  held  somewhat  perpendicularly,  in  which 
position  it  is  inserted,  beak  downward,  against  the  floor  of  the  nasal 
vestibule  (Fig.  107).  The  hand  holding  the  catheter  is  then  lifted 
until  the  instrument  is  horizontal  and  its  beak  rests  upon  the  floor  of 
the  nostril,  in  which  position  it  is  advanced,  with  the  most  gentle  effort 
possible,  along  the  entire  length  of  the  floor  of  the  inferior  meatus  and 
until  the  distal  end  is  felt  to  move  with  such  freedom  as  to  indicate 
its  entrance  into  the  nasopharynx.  It  is  absolutely  necessary  in  order 
to  insure  final  success  that  the  instrument  shall  follow  the  floor  of  the 


1 86 


THE    PRINCIPLES   AND    PRACTICE    OF   OTOLOGY 


Front.il  sinus 

,     Superior  turbinate 
,/         ,- Middle  turbinate 
x'       , ^Inferior  turbinate 
f.    Sp>henoidal  sinus 


Nasopharyngeal 

mouth  of  Eus- 
tachian   tube 


« \ .  Fossa  of  Rosen- 
t\       miiller 


Soft  palate 


Uvula 

\ 
Hard  palate 

FIG.  TOO. — CATHETER  PROPERLY  INSERTED  THROUGH  THE  INFERIOR  MEATUS. 

The  illustration  shows  the  position  of  the  instrument  when  withdrawn  until  the  arc  of  the  distal  end  hugs 
the  posterosuperior  surface  of  the  soft  palate.  The  same  position  of  the  guide  is  shown  in  Fig.  i:c,  and  of 
the  beak  in  Fig.  112,  A.  If  the  shaft  of  the  catheter  is  rotated  outward  until  the  guide  points  toward  the  outer 
canthus  of  the  eye  of  the  same  side,  Fig.  in,  the  beak  of  the  instrument  will  enter  the  pharyngeal  orifice  of 
the  tube  Fig.  112,  C. 


FIG.  109. — FALSE  POSITION  OF  THE  EUSTACHIAN  CATHETER. 

Introduction  of  the  instrument,  as  here  shown,  is  a  frequent  cause  of  failure  in  the  beginner  to  properly 
enter  the  nasopharyngeal  orifice  of  the  tube.  While  in  the  position  here  shown  it  is  impossible  to  rotate  the 
instrument  into  the  mouth  of  the  tube. 


THE    METHODS   OF    THE    EXAMINATION   OF   THE    PATIENT 


i87 


inferior  meatus  during  this  step  of  its  passage  (Fig.  108),  since  it  must 
be  clear  that  should  it  be  directed  so  as  to  cross  the  inferior  turbinated 
body  as  shown  in  Fig.  109,  it  could  never  be  turned  into  the  Eus- 
tachian  meatus. 

"When  the  distal  end  has  reached  the  open  space  of  the  nasopharynx, 
with  the  beak  of  the  instrument  still  pointing  downward  and  the  shaft 
resting  upon  the  nasal  floor,  the  catheter  should,  without  undergoing 
the  slightest  rotation,  be  gently  withdrawn  until  the  concave  surface 


FIG.    no. — POSITION    OF    THE    GUIDE    WHEN  FIG.  m. — POSITION  or  THE  GUIDE  WHEN  THE 

CATHETER  is  INSERTED  ALONG  FLOOR  OF  INFERIOR  CATHETER  is.  PROPERLY  INSERTED  INTO  THE  XASO- 

MEATUS,  AND  HAS  THEN  BEEN  DRAWN  OUTWARD  PHARYNGEAL  ORIFICE  OF  THE  TUBE. 

UNTIL  THE  ARC  OF  THE  DISTAL  EXTREMITY  HUGS  THE  This  position  of  the  guide  corresponds  with  that  of  the 

SUPEROPOSTERIOR  SURFACE  OF  THE  SOFT  PALATE.  beak  when  rotated  to  point  C,  Fig.  112. 

This  same  position  of  the  whole  instrument  is 
shown  in  Fig.  108,  and  the  position  of  the  beak  is 
seen  at  point  A,  Fig.  112. 

of  the  curve  firmly  hugs  the  upper  posterior  surface  of  the  soft  palate 
(Fig.  no).  In  this  position  the  instrument  is  ready  to  be  turned  into 
the  orifice  of  the  Eustachian  tube,  the  mouth  of  which  is  easily  entered 
by  the  beak,  provided  the  catheter  is  moved  neither  inward  nor  out- 
ward during  its  rotation.  To  provide  against  such  movement  the  part 
of  the  instrument  which  protrudes  from  the  nostril  is  grasped  and  held 
in  position  by  the  thumb  and  forefinger  of  the  left  hand  while  the  re- 
maining fingers  of  this  hand  are  supported  against  the  patient's  head, 
in  which  position  the  catheter  is  rotated  outward  by  the  right  hand 
until  the  guide  points  toward  the  outer  canthus  of  the  eye  of  the 


1 88 


THE   PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 


same  side.  Fig.  in  illustrates  the  position  of  the  guide,  while  point  C, 
Fig.  112  shows  that  of  the  beak  at  the  time  of  the  completion  of  the 
procedure. 

(b)  Second  Method, — If  for  any  reason  the  first  method  should 
fail,  the  instrument  should  be  rotated  inward  until  the  guide  projects 
horizontally  toward  the  opposite  side,  which  will  bring  the  beak  to 

point  B,  (Fig.  mj.  In  this  position 
it  is  withdrawn  until  the  curved  distal 
end  of  the  catheter  hooks  snugly  over 
the  posterior  end  of  the  nasal  sep- 
tum. It  is  then  held,  as  above  de- 
scribed, by  the  thumb  and  forefinger 
to  prevent  either  an  outward  or  in- 
ward displacement,  while  at  the  same 
time  it  is  rotated  outward  until  both 
guide  and  beak  occupy  the  position 
shown  in  Figs,  in  and  112. 

(c]  Third  Method.—  If  desired  or 
if  required  by  circumstances  after  the 
catheter  has  entered  the  nasopharyn- 
geal  space  it  may  be  pushed  further 
in  until  the  beak  touches  the  posterior 
wall  of  the  nasopharyngeal  cavity.  It 
is  then  slightly  withdrawn  and  rotated 
until  the  guide  points  horizontally  to- 
ward the  side  to  be  catheterized.  In 
this  position  it  is  gently  drawn  out- 
ward along  the  lateral  pharyngeal 
wall,  the  beak  first  passing  the  fossa 
of  Rosenmiiller,  then  rising  over  the 

i  -n.iii_»    .in.i     Una  ^i  inuc    w  MI   ii    me     |H)>iin)il    UI   U1C  •  i  •  f        •     -I  1  1 

guide  shown  in  Fig.  »o  is  reached.   B  shows     posterior  lip  ot    the    nasopharyngeal 

orifice  of  the  Eustachian  tube,  and 
finally  dropping  into  its  mouth;  the 
instrument  is  then  rotated  into  the 
position  shown  in  Fig.  in.  This 

latter  method,  because  of  the  irritation  likely  to  be  produced  upon 
the  nasopharyngeal  structures  and  the  consequent  possibility  of  the 
patient  coughing  or  retching,  is  not  to  be  recommended  except  after 
failure  of  the  other  methods  already  described. 

Difficulties  Sometimes  Encountered  during  Catheterization.— 
Undue  anxiety  on  the  part  of  the  patient  or  a  hypersensitive  nasal 


FIG.  112. — THE  POSTERIOR  XARES  AND 
POSTERIOR-UPPER  SURFACE  OF  THE  SOFT  PALATE 
AND  UVULA,  SHOWING  THE  DIFFERENT  POSI- 
TIONS OF  THE  BEAK  OF  THE  F.USTACHIAN  CATH- 
ETER DURING  THE  SEVERAL  STEPS  OF  ITS  INSER- 
TION INTO  THE  NASOPHARYNGEAL  ORIFICE  OF 
THE  TUBE. 

A,  the  position  when  first  inserted;  the  shank 
of  the  instrument  lies  upon  the  floor  of  the  inferior 
meatus,  and  the  curve  hugs  the  posterosuperior 
surface  of  the  soft  palate. 

If  the  instrument  is  turned  from  this  posi- 
tion toward  the  Eustachian  orifice,  C,  it  will 
usually  enter  this  orifice  when  the  position  of  the 


the  position  of  the  beak  when  the  catheter  is 
drawn  forward  until  it  closely  hugs  the  posterior 
end  of  the  nasal  septum  (second  method).  If 
rotated  in  the  direction  of  C  it  will  usually  enter 
the  pharyngeal  tubal  orifice. 


THE    METHODS   OF   THE   EXAMINATION    OF   THE    PATIENT  189 

or  nasopharyngeal  mucous  membrane  will  sometimes  incite  a  faucial 
spasm  during  the  performance  of  Eustachian  catheterization.  If  the 
distal  end  of  the  catheter  has  already  entered  the  nasopharynx  and  a 
muscular  spasm  is  thereby  incited,  the  instrument  is  suddenly  grasped 
by  the  muscular  contraction  with  such  firmness  that  it  becomes  for  the 
time  immovably  fixed,  and  to  turn  it  into  proper  position  would  require 
a  force  sufficient  to  greatly  injure  the  surrounding  soft  parts  and  to 
cause  the  patient  much  needless  anxiety  and  pain.  When  thus  locked 
in  the  muscular  grasp  of  the  palate  and  pharynx  non-interference  is 
recommended  until  the  spasm  has  relaxed.  The  instrument  is,  there- 
fore, allowed  to  remain  in  the  nose  unmolested,  while  the  patient  should 
be  assured  that  the  difficulty  will  rapidly  subside.  The  patient  is  re- 
quested to  open  the  eyes  and  mouth,  to  inhale  deeply  through  the  nose, 
and  to  refrain  from  swallowing  or  talking.  Immediate  relaxation  usually 
results  when  these  instructions  are  followed  by  the  patient  and  the  cathe- 
ter is  again  found  free  in  the  nostril.  The  uncompleted  step  of  turning 
the  beak  into  the  Eustachian  tube  may  then  be  accomplished  or,  if 
the  patient  continues  to  be  nervous  concerning  the  matter  and  the 
faucial  muscles  are  still  unduly  excitable,  the  instrument  should  be 
withdrawn  and  no  further  attempt  be  made  to  insert  it  until  a  future 
examination. 

How  may  the  operator  prove  that  the  beak  of  the  catheter  has 
properly  entered  the  mouth  of  the  Eustachian  tube  ?  The  experienced 
otologist  recognizes  the  correct  position  of  his  instrument  by  an  almost 
indefinable  sense  of  touch.  A  more  definite  knowledge  concerning  the 
subject  is,  however,  desirable  on  the  part  of  the  learner,  and  therefore 
the  following  points  will  prove  helpful  in  this  respect: 

(a)  When  the  catheter  is  in  proper  place  the  guide  should,  as  has 
already  been  stated,  point  toward  the  external  canthus  of  the  eye  of 
the  same  side  of  the  patient's  head.  If  the  guide  should  point  in  either 
a  higher  or  lower  direction  it  is  not  probable  that  the  catheterization 
has  been  successfully  performed.  (&)  When  the  beak  of  the  instrument 
is  once  in  proper  position  in  the  nasopharyngeal  mouth  of  the  Eus- 
tachian tube  a  sense  of  resistance  is  met  when  the  attempt  is  made 
either  to  advance  or  withdraw  the  instrument,  the  sense  of  lodgment 
of  the  beak  within  a  cavity  being  imparted  to  the  hand  of  the  operator. 
(c)  After  the  catheter  has  been  successfully  introduced  into  the  tubal 
mouth  the  patient  experiences  no  pain  or  discomfort  should  he  then 
attempt  to  talk  or  swallow,  whereas  if  failure  to  enter  the  mouth  of  the 
tube  has  resulted,  any  such  movement  of  the  throat  will  cause  no  incon- 
siderable distress,  (d)  By  the  proper  interpretation  of  the  sounds 


1 90  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

heard  through  the  diagnostic  tube  by  the  examiner  during  the  inflation 
of  the  middle  ear. 

Aural  Auscultation. — Tympanic  inflation,  when  produced  by  any  of 
the  foregoing  methods,  causes  certain  well-defined  sounds  in  one  or 
more  divisions  of  the  hearing  tract,  which  may  be  perceived  by  the  ear 
of  the  examiner,  should  his  ear  be  connected  by  means  of  the  ausculta- 
tion tube  (Fig.  113)  with  that  of  the  patient.  The  sounds  thus  produced 


FIG.  113. — DIAGNOSTIC  TUBE. 

are  either  normal  or  abnormal,  according  as  the  cavities  through  which 
the  air  passes  are  in  a  state  of  health  or  have  been  altered  in  size  and 
shape  as  a  result  of  diseased  processes.  It  is  because  of  the  possibility 
of  distinguishing  the  abnormal  from  the  normal  sounds  that  aural 
auscultation  is  of  importance  as  a  diagnostic  measure. 

The  sound  perceived  by  the  listener  during  the  inflation  of  the 
normal  ear  is  a  compound  one,  and  made  up,  first,  by  the  rapid  passage 
of  the  air  through  the  narrow  Eustachian  tube;  second,  by  its  slower 


THE   METHODS    OF   THE   EXAMINATION   OF   THE   PATIENT  IQI 

accumulation  and  vibration  within  the  tympanum,  and,  third,  by  the 
displacement  of  the  drum  membrane  outwardly.  Normal  auscultatory 
sounds,  being  of  complex  formation,  are  not  easy  of  accurate  description, 
and  must  be  repeatedly  heard  by  the  examiner  before  a  correct  inter- 
pretation of  their  character  is  possible.  Politzer  compares  this  sound 
to  that  produced  by  placing  the  tongue  against  the  roof  of  the  mouth 
and  then  quickly  performing  expiration  between  the  partly  closed  lips. 
Because  of  the  small  amount  of  secretion  present  in  the  normal  tube 
and  middle  ear  the  auscultation  sound  of  such  an  ear  is  always  dry. 
The  note  produced  is  moderately  low,  but  varies  in  pitch  with  the 
force  used  in  inflation,  with  the  lumen  of  the  catheter  employed,  and 
with  the  normal  differences  in  the  size  and  conformation  of  the  cavities 
through  which  the  air  passes.  The  sound  which  results  from  the 
inflation  seems  close  to  or  even  in  the  examiner's  own  ear. 

The  sound  produced  by  inflation  through  a  catheter,  the  beak  of 
which  has  not  been  properly  placed  in  the  mouth  of  the  Eustachian 
tube,  will  seem  far  removed  from  the  examiner's  ear  and  will  produce 
no  impulse  upon  the  latter;  but  after  having  been  frequently  heard  and 
compared  with  tubal  or  tubotympanic  sounds,  can  be  readily  inter- 
preted as  originating  from  the  nasopharynx.  If  the  cleansing  of  the 
nasopharynx,  which  should  have  been  done  as  a  preparation  for  Eus- 
tachian catheterization,  has  been  imperfectly  accomplished  the  tubal 
orifice  may  contain  a  quantity  of  ropy  mucus  sufficient  to  fill  it.  Under 
such  circumstances  the  catheter  may  have  been  properly  placed,  but 
the  air  would  of  course  fail  to  enter  the  tube,  and  the  sound  produced 
by  its  passage  through  the  tenacious  secretion  will  be  distant  and  dis- 
cordant. Repetition  of  the  efforts  at  inflation  will  usually  displace 
the  mucus  and  finally  permit  the  air  to  enter  the  tympanum,  after 
which  the  normal  bruit  \vill  be  heard. 

Pathologic  changes  within  the  Eustachian  tube  or  tympanum  will 
greatly  change  the  character  of  the  normal  inflation  bruit.  If  the 
Eustachian  tube  is  occluded  by  tenacious  secretion,  by  swelling  of  the 
mucous  lining,  or  by  proliferative  changes  in  its  walls,  the  inflated  air 
cannot,  of  course,  reach  the  middle  ear  and  the  inflation  sound  will 
seem  correspondingly  distant.  Should  the  tympanum  be  wholly  or 
partially  filled  with  polypoid  or  hyperplastic  tissue,  the  normal  blowing 
sound  will  be  either  greatly  reduced  or  entirely  absent.  Accumulations 
of  mucus,  serum,  or  pus  within  the  middle  ear  are  productive  during 
inflation  of  bubbling  or  crackling  noises,  due  to  the  passage  of  the  air 
through  the  liquid.  Such  sounds  are,  however,  only  possible  when  the 
exudate  is  sufficient  in  quantity  to  rise  above  the  level  of  the  tympanic 


192  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

orifice  of  the  Eustachian  tube  or  when  the  patient  inclines  his  head  to 
the  opposite  side  during  the  inflation. 

Small  perforations  through  the  membrana  tympani,  which  are  located 
in  any  portion  of  the  membrana  vibrans,  will  give  rise  to  a  perforation 
whistle  which  is  usually  intense  enough  to  be  heard  at  a  distance  of 
several  feet  from  the  patient  without  the  use  of  the  auscultation  tube. 
Such  a  whistle  is  not  produced  if  the  perforation  is  blocked  by  polypi 
or  if  the  location  of  the  rupture  is  distant  from  the  tympanic  tubal 
orifice.  Sometimes  adhesions  of  the  membrane  to  the  adjacent  inner 
tympanic  wall  will  shut  off  that  portion  of  the  middle  ear  which  is  in 
communication  with  the  Eustachian  tube,  and  for  this  reason  no  per- 
foration sound  is  heard  during  the  inflation.  Perforations  in  Schrap- 
nell's  membrane  are,  for  the  above  reasons,  not  productive  of  this  very 
characteristic  sound. 

Fatal  Results  jrom  Catheter ization. — The  fact  that  3  deaths  have 
been  reported  as  a  result  of  Eustachian  catheterization  proves  nothing 
more  than  that  force  and  awkwardness  have  been  employed  instead 
of  that  most  gentle  dexterity  which  alone  is  justifiable,  and  which  will 
be  entirely  sufficient  to  insure  successful  catheterization  in  any  case 
where  this  procedure  is  a  proper  one  to  employ.  The  deaths  were  due 
to  emphysema  of  the  tissues  of  the  neck.  The  beak  of  the  catheter 
had  abraded  the  mucous  membrane  and  the  subsequent  efforts  to 
inflate  the  drum-cavity  resulted  in  the  injection  of  air  directly  into  the 
tissue  of  the  neck  in  exactly  the  same  manner  that  air  is  injected  with 
the  blow-pipe  when  this  instrument  is  used  to  facilitate  tissue  dissection. 
Such  an  accident  need  never  be  feared  when  the  catheter  is  used  in  a 
skilful  or  even  careful  manner. 


CHAPTER  XVIII 
EXAMINATION  OF  THE  FUNCTION  OF  THE  EAR 

A  GREAT  majority  of  all  the  diseases  of  the  hearing  apparatus  are 
accompanied  by  deafness  varying  in  degree  from  an  impairment  so 
slight  that  it  is  scarcely  noticeable  to  the  individual  to  that  in  which 
the  hearing  is  altogether  lost. 

The  examiner  will  have  ascertained,  as  a  result  of  the  previous 
physical  examination,  the  amount  and  nature  of  the  pathologic  changes 
that  have  taken  place  in  the  conducting  portion  of  the  ear;  but  from 
physical  appearances  alone  he  will  be  unable  in  the  vast  majority  of 
cases  to  state  with  any  positive  degree  of  accuracy  the  effect  such  changes 
have  had  upon  the  function  of  the  organ.  The  physical  examination 
will  also  fail  to  indicate  whether  the  impairment  is  altogether  one  of 
perception  or  of  conduction.  The  purpose  of  the  functional  examina- 
tion is,  therefore,  to  determine  the  degree  of  deafness,  and  to  ascertain 
•  whether  or  not  the  disease  responsible  for  the  same  is  located  in  the 
conducting  or  in  the  labyrinthine  portion  of  the  ear. 

The  room  in  which  a  functional  examination  is  to  be  made  should, 
if  possible,  be  well  removed  from  street  noises,  since  a  confusion  of 
sounds  from  without  will  greatly  lessen  the  value  of  any  conclusion 
which  may  be  derived  from  an  investigation  conducted  under  such 
circumstances.  The  room  should  also  be  of  sufficient  length  to  permit 
the  examiner  to  carry  out  some  of  the  tests  at  a  distance  from  the  patient 
of  at  least  15  feet. 

Since  the  normal  ear  is  capable  of  perceiving  both  the  quantity  and 
quality  of  sound,  certain  sound-producing  instruments  in  which  the 
one  or  the  other  of  these  elements  predominates  are  respectively  used 
in  the  functional  examination  in  order  to  determine  the  power  the 
diseased  organ  may  have  for  detecting  the  same,  and  by  this  means 
to  form  a  basis  for  estimating  the  loss  of  function  it  has  sustained. 

The  most  useful  quantitative  tests  are  made  by  using  the  watch,  the 
voice,  the  whisper,  and  Politzer's  acumeter;  but  before  describing  the 
methods  of  their  employment,  certain  precautions  in  their  use  should 
be  mentioned. 

Accurate  information  concerning  the  hearing  distance  of  a  diseased 

13  193 


1 94  THE   PRINCIPLES   AND   PRACTICE    OF   OTOLOGY 

ear  can  only  be  obtained  when  the  patient  is  not  permitted  to  see  the 
source  of  the  sound  used  in  the  test.  This  is  particularly  true  when  the 
voice  or  whisper  is  used  in  testing,  because  it  is  a  well-known  fact  that 
those  who  are  unable  to  hear  distinctly  very  soon  learn  to  read  the  lips 
of  those  with  whom  they  are  speaking.  The  patient  should,  therefore, 
be  seated  with  the  affected  ear  toward  the  examiner,  which  position 
will  not  only  be  the  best  for  perceiving  the  sound,  but  will  also  guard 
against  his  obtaining  information  concerning  it  otherwise  than  through 
audition.  In  children  all  tests  are  often  unreliable  unless  much  tact  is 
used  in  their  employment.  The  child  will  often  state  that  he  hears  the 
tick  of  the  watch  or  the  click  of  an  acumeter  at  impossible  distances; 
in  which  instance  it  will  be  found  more  satisfactory  to  use  the  voice  test. 
If  too  young  to  understand  and  repeat  some  number  which  the  examiner 
pronounces,  the  simplest  words  which  are  known  to  all  children,  as 
"papa,"  "mamma,"  or  "brother,"  may  be  spoken  by  the  examiner 
either  in  voice  or  whisper,  and  if  the  same  are  repeated  by  the  child  the 
inference  concerning  his  hearing  power  for  the  voice  or  whisper  may  be 
conclusively  known.  It  is  obviously  necessary  to  have  the  patient, 
whether  child  or  adult,  repeat  the  spoken  or  whispered  words. 

The  Watch  Test. — This  ever-ready  means  of  determining  the 
degree  of  hearing  is  quite  commonly  employed,  and,  although  it  often 
gives  rise  to  erroneous  impressions,  it  is  not  without  merit.  During 
the  examination  the  watch  should  be  held  at  that  distance  from  the  ear 
at  which  it  is  known  to  be  normally  heard,  and  then  gradually  be  brought 
nearer  until  the  hearing  distance  for  the  ear  in  question  is  ascertained. 
If  the  watch  is  first  held  near  the  affected  ear  and  is  then  gradually 
removed  from  it  in  order  to  learn  the  distance  at  which  it  may  be  heard, 
it  will  often  be  found  that  the  hearing  distance  is  greater  for  the  latter 
than  it  is  for  the  former  method,  for  the  reason  that  when  the  tick  is 
once  perceived  by  the  patient  the  impression  upon  the  impaired  ear 
will  persist,  even  when  the  watch  is  removed  beyond  the  point  at  which 
it  could  possibly  be  heard. 

For  the  purpose  of  recording  the  results  of  the  watch  test  the  hearing 
power  of  any  individual  may  be  described  by  taking  the  number  of 
inches  at  which  the  watch  in  use  is  normally  heard  for  the  denominator, 
and  the  number  of  inches  it  is  heard  by  the  affected  ear  for  the  numerator. 
Thus,  the  normal  hearing  distance  for  a  given  watch  may  be  5  feet, 
whereas  the  patient  hears  it  only  2  feet.  The  record  for  such  a  case 
should  read,  "Hearing  power  for  watch  equals  fij."  Normal  hearing 
in  such  a  case  would,  of  course,  be  f  $. 

It  should  be  stated  that  many  partially  deaf  persons  hear  the  watch 


EXAMINATION   OF   THE    FUNCTION   OF   THE    EAR  195 

tick  comparatively  well,  whereas  they  perceive  the  voice  comparatively 
poorly,  and  that  therefore  an  improvement  in  the  hearing  distance  for 
the  watch,  as  the  result  of  treatment,  may  not  be  a  source  of  satisfaction 
to  the  patient,  for  the  practical  reason  that  it  is  the  voice  and  not  the 
watch  that  he  most  desires  to  hear. 

The  Voice  Test. — A  mild  degree  of  deafness  may  be  present  and 
yet  the  patient  may  hear  ordinary  conversation  with  entire  satisfaction. 
This  is  due  to  the  fact  that  the  normal  perceptive  power  is  greater  than 
is  necessary  for  the  usual  purposes  of  life.  In  cases  of  slight  deafness 
the  patient  is  annoyed  by  his  defect  only  when  the  speaker  is  at  a  dis- 
tance, as  when  following  a  lecture  or  sermon,  or  when  in  a  company, 
several  individuals  of  whom  are  engaged  in  conversation  at  the  same 
time.  Whatever  may  be  the  degree  of  impairment,  it  is  important  that 
the  hearing  distance  for  the  conversational  voice  be  accurately  determined 
and  recorded.  The  pitch  of  the  examiner's  voice  should  not  be  raised 
above  the  normal  unless  it  is  first  ascertained  by  trial  that  the  conversa- 
tional voice  cannot  be  heard  by  the  patient.  Many  patients  will  hear 
the  pure  notes  of  the  speaking  voice  much  better  than  they  will  if  the 
same  be  pitched  an  octave  or  more  higher.  A  shrill  voice  is  especially 
confusing  to  those  suffering  from  certain  forms  of  labyrinthine  affection. 
If  both  ears  are  about  equally  diseased,  it  is  easier  to  obtain  accurate 
results  from  the  voice  test  than  in  cases  where  only  one  is  defective.  In 
the  latter  instance  it  is  necessary  to  block  the  auditory  canal  of  the  sound 
ear  during  the  examination,  which  may  be  accomplished  by  the  patient, 
who  inserts  his  wetted  forefinger  tightly  into  the  external  meatus. 

When  the  voice  is  heard  at  a  distance  of  more  than  15  feet  the 
whisper  should  be  employed.  The  patient  is  told  to  repeat  what  he 
hears.  Standing  at  the  greatest  distance  from  the  patient  at  which  the 
whisper  is  likely  to  be  heard,  the  examiner  whispers  at  the  end  of  ex- 
piration, using  the  reserve  ah*.  This  method  gives  a  more  uniform 
whisper,  according  to  Bezold.  The  examiner  then  whispers  a  word 
or  a  number  of  two  figures.  If  this  is  not  heard,  the  examiner  gradually 
approaches  the  patient,  repeating  the  number  at  each  foot  of  the  prog- 
ress until  the  patient  hears  and  repeats  what  is  said.  If  the  opposite 
ear  is  also  to  be  examined,  a  different  set  of  numbers  or  words  should 
be  used  in  the  test,  because  when  once  a  given  word  is  perceived  it  will 
be  heard  or  guessed  much  more  readily  if  whispered  or  spoken  imme- 
diately afterward.  Thus  the  numbers  22,  46,  99,  etc.,  may  be  employed 
in  examining  one  ear,  and  24,  57,  88,  etc.,  for  the  other.  It  will  be 
found  that  words  containing  a  large  proportion  of  vowels  will  be  heard 
farther  than  those  made  up  largely  of  consonants.  Thus,  the  word 


196  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

Boston,  when  cither  whispered  or  spoken,  will  be  heard  at  a  greater 
distance  than  will  the  word  Massachusetts.  This  fact  must,  therefore, 
be  considered  in  making  a  comparison  of  results  obtained  at  the  several 
different  examinations  which  may  be  made  during  the  course  of  the 
treatment;  for  unless  words  are  used  at  each  test  which  contain  a  some- 
what similar  arrangement  of  vowels  and  consonants,  an  erroneous 
conclusion  as  to  the  progress  of  the  case  will  be  formed. 

Politzer's  Acumeter. — For  testing  the  hearing  of  those  who  are 
quite  deaf,  this  instrument  (Fig.  114)  pos- 
sesses decided  advantages,  but  because  of 
the  intensity  of  the  clicking  sound  produced 
by  it  the  milder  cases  can  be  better  examined 
by  the  foregoing  methods.  Acumeters  are 
so  constructed  that  they  always  produce 
approximately  the  same  note,  and  herein 

FIG.  114. — POLITZER'S  ACUMETKR. 

lies  their  value  when  it  is  desired  to  com- 
pare the  result  of  the  examinations  made  by  different  observers. 

A  comparison  of  the  results  of  the  foregoing  tests  cannot  be  satis- 
factorily made  when  either  the  watch  or  voice  tests  have  been  employed, 
for  the  obvious  reason  that  the  watch  used  by  one  examiner  may  represent 
a  make  of  instrument  which  ticks  with  an  entirely  different  intensity 
from  that  used  by  another;  and  the  voices  of  no  two  observers  are  likely 
to  have  an  identical  force  or  quality.  The  whisper  test,  when  produced 
as  above  directed,  is  more  nearly  the  same  for  all  persons,  and  therefore 
it  becomes  a  good  test  when  comparisons  are  to  be  made. 

Tuning-forks.— The  power  of  the  human  ear  for  the  perception 
of  sound  lies  within  the  limits  of  16  vibrations  per  second  as  a  minimum, 
'and  50,000  per  second  as  a  maximum.  In  the  majority  of  individuals 
a  rate  of  vibration  of  less  than  24  or  more  than  16,000  per  second 
are  not  perceived.1  It  is  probable  that  those  who  are  able  to  hear  a 
rate  either  lower  or  higher  than  those  last  given,  do  so  as  a  result  of 
musical  training. 

The  sound  produced  by  the  lower  number  of  vibrations  is  designated 
a  low  note,  while  that  which  results  from  rapid  vibrations  constitutes 
a  high  note.  The  hearing  power  may  be  impaired  for  the  detection 
of  either  the  higher  or  the  lower  notes,  and  it  is  of  great  importance 
in  diagnosis,  prognosis,  and  treatment  to  be  able  to  determine  which 
part  and  to  what  extent  the  musical  scale  is  defective  in  any  case  of 
deafness.  For  the  purpose  of  detecting  such  deficiencies  a  series  of 
tuning-forks  whose  rates  of  vibrating  cover  the  normal  limits  of  hearing 

1  Howell,  An  American  Text -book  of  Physiology,  1896. 


EXAMINATION   OF    THE    FUNCTION    OF   THE    EAR 


197 


would  be  necessary,  and  Bezold  has  actually  devised  such  a  set  of  forks 
and  whistles.  These,  while  possibly  essential  to  absolute  accuracy, 
are  fortunately  unnecessary  except  in  rare  instances  of  complicated 
aural  ailments.  The  Bezold  set  is  expensive  and  its  use  requires  more 
time  than  is  usually  justifiable. 

Hartmann's  set  of  tuning-forks  (Fig.  115)  consists  of  five  instruments 
ranging  from  C  =  128  to  d  —  2048  double  vibrations.  This  range 
is  usually  quite  sufficient  to  obtain  the  information  desired ;  and,  indeed, 


abed  e 

FIG.  115. — HARTMANN'S  SET  OF  TUNING-FORKS  RANGING  FROM  C  TO  €4  IN  SERIES,  AND   FROM  128  V  S  TO 

2048  V  S. 

the  knowledge  that  may  be  gained  from  the  use  of  the  forks  C,  C2, 
and  C4,  when  taken  in  connection  with  the  intelligence  gained  through 
the  physical  examination  of  the  ear  and  the  history  of  the  case,  is  often 
sufficient  to  justify  a  diagnosis  as  to  the  part  of  the  ear  affected  by  the 
disease,  as  well  as  the  degree  of  impairment  of  the  hearing. 

For  the  detection  of  the  upper  tone  limit  the  C4  fork  in  the  Hart- 
mann  set  is  not  always  sufficiently  high.  The  Galton  whistle  is  a 
serviceable  aid  in  such  instances.  Since  this  instrument  is  constructed 
like  an  adjustable  organ  pipe,  it  is  possible  to  obtain  as  low  as  16 


198  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

vibrations  per  second  or  as  many  as  50,000  per  second,  which  latter 
represents  the  maximum  normal  limit.  Likewise  in  cases  where  there 
is  but  slight  impairment  of  hearing,  the  C  fork  of  the  Hartmann  series 
will  not  be  low  enough  to  detect  the  defect,  and  in  such  instances  the 
use  of  Dench's  fork  (Fig.  116),  will  serve  a  useful  purpose.  The  three 
most  useful  tests  of  the  tuning-fork  in  determining  the  perception  of  an 
ear  for  the  quality  of  sound  are : 

(i)  The  Schivabach  Test. — The  value  of  this  test  depends  upon  the 
fact  first  established  by  Schwabach,  that  when  there  is  obstruction  to 
the  passage  of  sound  through  either  the  external  or  middle  ear,  a  vibrat- 
ing tuning-fork  will  be  heard  longer  when  placed  in  contact  with  the 
cranial  bones  than  it  will  through  the  air,  if  held  while  vibrating  near 


IMG.  116. — DENCH  FORK  FOR  TESTING  Low  TONE  LIMITS. 
With  clamps  80  V.  S. ;  without  clamps  120  V.  S. 

the  ear.  Thus,  if  the  patient  has  impaired  hearing  and  the  vibrating 
tuning-fork  is  heard  in  both  ears  longer  when  the  shank  of  the  instrument 
is  placed  against  the  forehead  than  it  is  when  held  at  a  short  distance 
from  either  one  or  the  other  ear,  the  inference  should  be  that  the  disease 
is  located  in  the  middle  ear  or  external  auditory  meatus,  in  which  in- 
stance it  is  properly  spoken  of  as  an  obstructive  deafness  or  a  deafness 
due  to  impairment  of  the  conducting  apparatus.  Should,  however,  the 
patient  who  is  partially  deaf  hear  the  vibrating  fork  longer  through 
the  air  than  through  the  bone,  the  fact  would  indicate  a  labyrinthine 
and  not  an  obstructive  aural  disease. 

In  all  the  tests  requiring  the  application  of  the  vibrating  instrument 
to  the  bone,  the  examiner  should  use  a  middle  fork,  the  one  most  com- 


EXAMINATION    OF   THE    FUNCTION   OF   THE    EAR  199 

monly  selected  being  C2}  Fig.  115,  b.  The  excursions  of  the  slowly 
vibrating  prongs  of  the  lowest  forks  (Fig.  116)  are  great  enough  to 
produce  a  sensation  upon  the  part  against  which  the  handle  of  the 
instrument  rests,  which,  in  view  of  the  fact  that  the  remaining  sensi- 
bilities of  those  who  are  deaf  are  greatly  increased,  may  be  felt  rather 
than  heard  by  the  patient.  While  the  Schwabach  test  is  entirely  reliable 
in  nearly  every  case,  certain  complicated  conditions  arise  that  sometimes 
render  it  uncertain,  in  which  instances  the  results  obtained  by  it  must 
be  compared  with  those  of  other  tests,  and  also  with  the  findings  of  the 
physical  examination  and  the  history  of  the  patient,  before  a  definite 
conclusion  is  reached. 

(2)  Weber's  test  depends  for  its  value  upon  the  physical   fact   that 
if  in  cases  of  one-sided  deafness  the  tuning-fork  is  placed,  while  vibrat- 
ing, upon  the  median  line  of  the  skull  it  will  be  unmistakably  heard  best 
in  the  deaf  ear,  provided  the  cause  of  the  deafness  is  in  the  middle  ear; 
whereas,  if  there  is  a  purely  labyrinthine  affection  present,  the  fork  will 
be  heard  best  in  the  healthy  ear.     Should  the  case  be  one  of  mixed 
deafness,  that  is,  should  there  be  disease  of  both  the  middle  ear  and 
labyrinth,    the    test    may    prove    uncertain   and    the    examiner    must 
seek  more   positive   information   through    the    employment    of   other 
measures.     If  the  implication  of  the  labyrinth  and    middle  ear  are 
equal  in  a  patient  who  is  quite  deaf  in  one  ear  the  chances  are  that 
the  vibrations  will  be  best  heard  in  the  good  ear;  whereas,  if  the  middle 
ear  is  the  more  involved  the  sound  will  be  best   heard  in  the  bad  ear, 
but  for  a  shorter  period  than  when  uncomplicated  by  a  labyrinthine 
involvement. 

(3)  Rinne's  Test. — In  this  the  experiment  of  comparing  the  length 
of  time  the  vibrating  fork  is  heard  through  the  air  when  held  near  the 
ear  with  that  for  which  it  is  heard  through  the  bone  when  it  is  placed 
upon  the  mastoid  process  is    performed.      Normally    the    C2  fork  is 
heard  twice  as  long  by  air  as  by  bone  conduction  (a  c  =  2  b  c).      If 
the  reverse  is  found  to  be  true,  this  fact  is  indicative  of  middle-ear 
deafness.     In   uncomplicated  labyrinthine  deafness  air  conduction  is 
better  than  bone  conduction  (^),  the  high  notes  are   heard    through 
the  air   comparatively   poorly   and  the  low  notes  comparatively  well. 
When  the  vibrating  fork  is  heard  longest  by  air  conduction,  Rinne's 
test  is  said  to  be  positive    (Rinne+),   but  if  heard  longest  when  the 
handle  is  placed  against  the  mastoid,  the  test  is  negative  (Rinne— ).     In 
those  in  whom  the  hearing  distance  for  the  forced  whisper  is  less  than 
6  feet,  Rinne's  test  is  not  the  best  one  to  employ. 

Summary  of  the  Various  Tuning-fork  Tests  and  of  the  Inter- 


200  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

pretation  of  the  Results  Obtained  from  Each,  or  from  All  Used 
Collectively.— (a)  Evidence  Furnished  by  the  Use  oj  the  Tuning-fork 
which  is  Indicative  of  Middle-ear  Deafness. — In  any  partially  deaf 
individual  the  hearing  for  the  lower  tone  limit  by  air  conduction  is  raised; 
that  is,  if  the  patient  does  not  hear  C  (Fig.  115,  a)  by  air  conduction, 
this  fact  is  usually  indicative  of  middle-ear  deafness.  If  then  Weber's 
test  is  applied,  the  vibrating  C2  fork  being  placed  on  the  median  line 
of  the  cranium,  and  the  patient  hears  the  vibration  best  in  the  bad  ear, 
this  fact  furnishes  further  evidence  that  the  disease  is  located  in  the 
middle  ear.  Should  additional  evidence  be  necessary  and  the  Rinne 
experiment  be  performed  and  found  negative,  the  diagnosis  of  middle- 
ear  deafness  may  then  be  safely  made. 

(b)  Evidence  Indicative  of  Labyrinthine  Affection. — When  the  exam- 
ination is  conducted  with  the  series  of  Hartmann  forks  and  C  is  heard 
by  air  conduction,  but  C3  and  Ci  (Fig.  115,  d  and  e]  are  not  so  heard, 
or  heard  but  poorly,  labyrinthine  disease  should  be  suspected.  Should 
€2  (Fig.  115,  b)  be  then  placed  upon  the  median  line  of  the  skull  and  the 
vibration  is  better  heard  in  the  better  ear,  the  former  suspicion  is  further 
confirmed;  and,  finally,  if  Rinne's  test  is  positive  (Rinne+,  *-£),  the 
diagnosis  of  labyrinthine  disease  should  be  made. 

In  addition  to  the  evidence  obtained  by  the  use  of  the  tuning-fork 
for  the  purpose  of  locating  the  disease  either  in  the  conducting  or  per- 
ceptive portions  of  the  hearing  apparatus,  the  facts  obtained  by  the 
physical  examination  are  often  of  great  value.  Thus,  in  cases  of  deaf- 
ness due  to  disease  of  the  conducting  apparatus  there  may  be  found 
in  the  external  auditory  meatus  obstructing  growths,  inspissated  cerumen, 
or  dried  pus.  The  tympanic  membrane  may  be  found  perforated, 
indrawn,  thickened,  or  adherent.  The  Eustachian  tube  may  be  swollen 
and  collapsed  or  narrow  and  strictured.  On  the  other  hand,  when  the 
functional  examination  points  to  the  labyrinth  as  the  sole  seat  of  the 
affection,  no  obstruction  whatever  will  likely  be  found  in  either  the 
external  auditory  meatus  or  Eustachian  tube,  provided  the  internal 
ear  disease  is  primary.  In  such  instances  the  drum  membrane  may 
appear  entirely  normal  in  every  respect.  In  case  the  internal  ear  disease 
is  a  complication  of  some  middle-ear  ailment,  all  of  the  above  changes 
that  were  noted  in  the  conducting  apparatus  may  be  found.  Any  one 
of  the  tuning-forks  which  is  selected  for  use  is  set  vibrating  by  holding 
the  shank  in  one  hand  and  striking  one  of  the  prongs  against  some 
object.  If  the  latter  be  hard,  as,  for  instance,  the  wood  or  marble  top 
of  a  table,  compound  notes  or  overtones  will  be  produced.  These  over- 
tones may  be  heard  by  the  patient,  whereas,  the  pure  tone,  the  ability 


EXAMINATION   OF    THE    FUNCTION    OF    THE    EAR  2OI 

of  the  patient  to  hear  which  the  examiner  desires  to  ascertain,  may 
not  be  at  all  perceived.  It  is,  therefore,  essential  that  some  semi-elastic 
substance,  like  the  operator's  knee,  be  struck  with  a  moderate  force, 
and  the  resulting  note  examined  by  his  own  ear  for  the  purpose  of 
detecting  any  overtone  before  the  vibrating  instrument  is  used  to  test 
the  hearing  of  the  patient.  The  vibrating  fork,  when  used  to  test  the 
air  conduction,  should  be  held  about  2  inches  from  the  ear  of  the 
patient  and  with  one  of  the  vibrating  prongs  directed  squarely  toward 
the  meatus.  If  the  instrument  is  rotated  from  this  position  a  point 
will  be  reached  at  which  the  vibrations  are  entirely  inaudible,  and 
consequently  the  test  might  be  rendered  unreliable. 


CHAPTER  XIX 

THE   INFLUENCE   OF  NASAL  AND  NASOPHARYNGEAL 
DISEASES    UPON   AFFECTIONS   OF   THE   EAR 

THE  anatomic  and  physiologic  relationship  of  the  nasal  and 
nasopharyngeal  spaces  to  the  cavities  of  the  middle  ear  is  so  intimate 
as  to  make  it  inevitable  that  continued  disease  of  the  former  must  sooner 
or  later  affect  the  latter. 

It  has  already  been  shown  that  certain  physiologic  processes  con- 
nected with  normal  hearing  are  mechanically  performed.  Thus  the 
normal  ventilation  of  the  tympanic  cavity  takes  place  during  the  act 
of  swallowing  and  is  the  result  of  a  muscular  traction  upon  the  walls 
of  the  Eustachian  tube  which  is  sufficiently  powerful  to  open  this 
channel  and  to  allow  that  "free  admission  of  air  which  is  at  all  times 
necessary  to  equalize  the  atmospheric  pressure  upon  the  tympanic 
side  of  the  drum  membrane. 

Any  growth  which  is  large  enough  to  fill  the  nasopharynx  must 
interfere  greatly  with  that  perfect  action  of  the  palatal  muscles  which 
is  constantly  taking  place  in  the  normal  throat,  and,  therefore,  with 
efficient  ventilation  of  the  cavity  of  the  middle  ear.  Normal  admission 
of  air  to  the  middle  ear  also  depends  at  all  times  upon  the  presence  in 
the  nasopharynx  of  an  unobstructed  supply  of  air.  Should  the  nose  or 
nasopharynx  be  obstructed  by  new  tissue,  each  act  of  deglutition  will 
exhaust  the  air  from  the  nasopharynx  and  tympanic  cavity  rather  than 
replenish  it.1 

Secondary  to  a  lowered  intratympanic  air  pressure  a  distention  of 
the  vessels  which  supply  the  mucous  membrane  of  the  middle  ear 
occurs.  When  continuing  for  any  considerable  length  of  time  this 
vascular  congestion  gives  rise  to  an  exudate  into  the  cavity  of  the  middle 
ear  (see  p.  235),  which  may  cause  rupture  of  the  membrana  tympani, 
or  may  remain  permanently  and  become  ultimately  organized  into  new 

1  This  fact  may  be  demonstrated  by  any  one  upon  himself.  Catch  the  alae  nasi  be- 
tween the  thumb  and  forefinger  of  one  hand  and  compress  tightly.  Then  swallow  while 
the  passage  of  air  through  the  nose  is  thus  completely  blocked.  A  sensation  of  stuffiness 
is  immediately  produced  in  both  ears  which  is  caused  by  the  exhaustion  of  air  from  the 
middle  ear  and  the  consequent  displacement  of  the  membrana  tympani  inward  by  the 
unequal  atmospheric  pressure  upon  the  outer  surface  of  the  drum-head. 
202 


INFLUENCE   OF   NASAL   AND    NASOPHARYNGEAL    DISEASES  203 

tissue.  The  engorgement  of  these  intratympanic  vessels  also  predis- 
poses the  individual  to  an  active  inflammation  of  the  middle  ear,  of 
either  a  catarrhal  or  suppurative  variety,  the  inflammatory  state  being 
quickly  added  to  that  of  congestion  whenever  a  sufficient  number  of 
pathogenic  bacteria  find  entrance  to  the  cavity  of  the  middle  ear. 

Individuals  who  are  affected  by  growths  in  the  upper  air  tract 
are  subjects  of  frequent  colds  in  the  head.  This  is  true  to  the  extent 
that  many  children  are  seldom  free  from  nasal  stuffiness  and  discharge 
except  during  a  short  time  each  year  in  summer,  and  medicines,  local 
applications,  or  hygienic  management  of  the  patient  seems  to  have 
little  or  no  effect  upon  this  condition  so  long  as  the  obstructed  air  tract 

remains. 

ADENOIDS1 

Pathogenic  bacteria  are  now  known  to  play  an  important  part  in 
the  production  of  aural  affections,  and  it  is  to  some  extent  because 
adenoids  and  other  growths  of  the  nasopharynx  form  an  ideal  culture- 
field  for  these  germs  that  the  presence  of  such  growths  become  most 
harmful.  The  mechanical  irritation  caused  by  the  presence  of  adenoids 
induces  an  abnormal  secretion  of  thick,  ropy  mucus,  which,  because  of 
the  obstructed  condition  of  the  nostrils,  is  difficult  and  often  impossible 
to  completely  dislodge.  The  retention  of  this  almost  purely  albuminoid 
secretion  at  a  proper  temperature  is  attractive  to  several  varieties  of 
bacteria  which  are  found  here  in  great  numbers,  and  which  are  appar- 
ently ready  at  all  times  to  invade  the  middle  ear  whenever  certain  con- 
ditions of  congestion  or  other  weakened  state  of  the  membrane  occurs 
in  that  cavity.  (See  Chapter  III.) 

The  author  believes  that  nasal  and  nasopharyngeal  obstruction  due 
to  adenoids  or  other  growths  constitute  the  most  frequent  and  harmful 
factor  in  the  causation  of  aural  diseases.  A  very  considerable  per- 
centage of  all  ear  affections  have  their  incipiency  in  childhood,  and 
therefore  at  a  period  of  life  before  the  patient  is  old  enough  to  realize 
the  degree  of  his  defect  or  to  make  any  complaint  of  the  impairment  of 
his  hearing.  Tubotympanic  congestion  with  resulting  exudate  into  the 
middle  ear  is  a  common  complication  of  nasopharyngeal  disease.  It 
is  not  often  a  painful  affection,  and  parents  are  therefore  seldom  alarmed 
concerning  its  indefinite  continuance;  indeed,  they  seem  to  be  very 
infrequently  cognizant  in  any  way  of  the  existence  of  an  affection  that 

1  While  the  term  adenoids  is  commonly  used  to  describe  hypertrophied  lymphoid 
tissue  in  the  vault  of  the  pharynx,  the  word  adenoid  would  be  more  correct  for  the  reason 
that  the  several  lobes  of  which  the  growth  is  composed  are  attached  to  but  one  base. 
When  removed  en  masse  by  one  sweep  of  the  curet,  as  advocated  in  the  text,  the  hyper- 
trophy conies  away  in  one  piece  as  shown  in  Figs.  129  and  130. 


204 


THE    PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 


may  in  the  future  debar  the  individual  from  active  participation  in 
social  or  commercial  life.  The  listless  appearance  and  the  semi-idiotic 
facial  expression  of  the  child  are  sometimes  overlooked  entirely  by 
those  who  are  constantly  with  such  children,  and  if  observed  are  usually 
attributed  to  a  habit  of  inattention,  for  which  the  child  is  unjustly 
faulted  both  at  home  and  at  school. 

Earache  is  a  frequent  complaint  of  the  child  afflicted  with  adenoids. 
The  most  trivial  exposure  to  cold  or  dampness  is  frequently  followed 
by  a  head  cold,  this  is  often  quickly  succeeded  by  pain  in  the  ear,  and 
later  by  a  serous,  mucous,  or  purulent  discharge  from  the  external 
auditory  meatus.  The  frequency  of  the  attacks  of  this  nature  in  adenoid 
children  is  sufficient  to  cause  serious  interruptions  in  their  attendance 
at  school;  and  this,  together  with  their  limited  ability  to  hear  what  is 
.  ;._  '  .'_^ said  when  their  physical  condi- 

tion permits  their  presence  in  the 
classroom,  is  quite  sufficient  to 
hinder  their  educational  progress 
to  an  extent  that  they  are  often 
rated  as  unduly  stupid. 

A  dull  eye,  widely  opened 
mouth,  peculiar  facial  expres- 
sion, and  general  appearance  of 
impaired  mentality  are  present  in 
the  typic  adenoid  case,  and  con- 
stitute a  condition  which  Guye 
has  designated  aprosexia  (Fig. 
117).  It  should  be  remem- 
bered, however,  that  a  large 
number  of  children  suffer  from 
adenoids  who  do  not  exhibit 
the  above  symptoms  to  any 
marked  extent.  Large  nasopharyngeal  growths  of  this  nature  are 
often  found  in  children  with  bright  faces,  who  possess  a  high  degree 
of  intelligence,  and  whose  parents  will  state  that  they  always  breathe 
with  the  mouth  closed.  Careful  investigation  in  such  instances  will 
show  that  the  parents  are  mistaken  and  that  mouth  breathing  is  complete, 
the  child  keeping  the  lips  separated  so  slightly  as  to  prove  deceptive  to 
the  casual  observer,  but  nevertheless  sufficiently  to  admit  the  inspired 
air.  A  painstaking  physical  and  functional  examination  of  this  class 
of  cases  will  almost  invariably  detect,  in  addition  to  the  adenoid  itself, 
the  presence  of  more  or  less  impairment  of  hearing.  It  may  be  stated 


FIG.  117. — TYPICAL  ADENOID  FACE. 
The  open  mouth,  expressionless  appearance,  impair- 
ment of  hearing  and  evil  effects  upon  the  general  health 
have  produced  the  condition  known  as  aprosexia. 


INFLUENCE    OF   NASAL    AND    NASOPHARYNGEAL    DISEASES          205 

by  the  parents  that  the  hearing  is  perfect,  and  this  may  apparently  be 
true  in  so  far  as  the  child's  ability  to  hear  common  conversation  is 
concerned,  but  since  it  is  true  that  normal  hearing  is  more  acute  than 
is  needed  for  the  perception  of  ordinary  conversational  tones,  it  is  like- 
wise true  that  some  of  the  hearing  power  may  be  lost  and  the  person 
or  those  about  him  be  unaware  of  the  fact,  unless  some  unusual  test 
is  brought  to  bear  upon  the  case. 

In  early  childhood  the  prompt  recognition  and  thorough  removal  of 
nasopharyngeal  adenoids  constitute  the  best  known  prophylactic  against 
future  deafness,  as  well  as  against  future  suppurative  aural  affections  and 
their  possible  mastoid  and  intracranial  complications.  At  this  period 
of  life  prompt  measures  directed  to  the  removal  of  these  obstructions 
from  the  upper  air  tract  will  in  a  majority  of  instances  cure  the  existing 
aural  disease,  and  will  prevent  in  a  great  measure  the  liability  of  its 
subsequent  occurrence.  Left  either  to  nature  or  to  medicinal  treatment, 
the  adenoid  is,  in  the  vast  majority  of  cases,  a  menace  to  the  integrity 
of  the  ear,  of  such  harmful  nature  that  few  of  those  who  are  so  fortunate 
as  to  be  allowed  to  "outgrow"  their  ailment  reach  adolescence  without 
serious  and  permanent  aural  impairment.  In  cases  of  deafness  accom- 
panying adenoids  in  childhood,  the  otologist  is  given  an  opportunity 
to  do  the  little  patient  an  immeasurable  and  permanent  good,  whereas 
the  same  individual,  if  allowed  to  continue  untreated  until  adult  life, 
will  then  frequently  present  the  most  hopeless  condition  in  so  far  as  cure 
or  relief  of  the  aural  condition  is  concerned.  The  entire  future  social 
and  commercial  welfare  of  this  heretofore  neglected  class  of  children 
depends  largely  upon  the  early  recognition  and  complete  removal  of 
this  comparatively  trivial  growth  from  the  nasopharynx;  and  since  the 
institution  of  compulsory  inspection  of  the  health  of  school  children, 
at  present  attracting  public  interest,  and  already  being  carried  out  in 
many  cities,  it  is  probable  that  an  earlier  recognition  of  the  causative 
factors  in  aural  disease  will  in  the  future  be  made,  and  that  as  a  con- 
sequence the  percentage  of  deafness  will,  even  in  the  next  generation, 
be  greatly  reduced. 

Although  adenoids  are  most  frequently  observed  in  childhood, 
and  the  aural  affections  for  which  the  growths  are  responsible  begin 
in  the  majority  of  instances  at  this  period  of  life,  these  obstructions 
not  infrequently  persist  into  adult  life.  Thus,  the  adenoid  vegetation 
that  blocks  the  respiratory  tract  of  the  child  almost  completely  prior 
to  the  age  of  ten,  is  often  believed  to  have  disappeared  entirely  before 
the  age  of  fifteen.  The  basis  for  this  belief  is  the  greater  ease  with 
which  the  individual  at  this  latter  age  is  able  to  breathe  through  the 


206  THE   PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 

nose.  A  physical  examination  of  the  nasopharynx  by  means  of  re- 
flected light,  the  post-rhinoscopic  mirror,  and  the  palate  retractor 
(Fig.  118)  will,  however,  demonstrate  the  fact  that  the  adenoid  has  not 
disappeared,  and  that  the  improved  nasal  breathing  is  largely  due  to 
the  rapid  enlargement  of  the  nasopharyngeal  space  which  takes  place 
at  the  age  of  puberty.  The  evil  consequences  of  the  adenoid  growth, 
therefore,  continue  indefinitely  to  act  mischievously  upon  the  ear, 
although  with  a  somewhat  lessened  activity.  When  untreated  sur- 
gically the  adenoid  slowly  undergoes  atrophy,  and  hence  when  the 
nasopharynx  is  examined  after  the  age  of  twenty-five  the  remaining 
hypertrophy  usually  appears  as  a  chronically  inflamed  and  thickened 
pad  of  lymphoid  tissue,  running  backward  across  the  roof  of  the  naso- 
pharynx from  the  vomer  in  front  and  extending  downward  a  variable 
distance  upon  the  posterior  wall  of  the  cavity.  Several  deep  fissures 
will  be  seen  traversing  the  flattened  mass,  all  of  which  run  in  an  antero- 
posterior  direction;  filling  these  fissures,  and  perhaps  spreading  from 


FIG.  118. — WHITE'S  SELF-RETAINING  PALATE  RETRACTOR. 

them  over  the  entire  nasopharynx  and  thence  downward  toward 
the  pharynx,  collections  of  thick  ropy  mucus  will  be  seen.  The  ex- 
aminer will  be  able  to  pass  a  properly  bent  probe  behind  the  palate, 
and,  guided  by  the  examining  mirror  to  explore  the  fissures  and  to 
note  their  number  and  depth.  The  method  of  making  the  post-rhino- 
scopic examination  is  shown  in  Fig.  119. 

After  the  age  of  thirty  the  adenoid  will  be  found  still  more  atrophied. 
It  frequently  persists,  however,  into  old  age  and  is  the  most  potent 
predisposing  factor  in  the  causation  of  chronic  nasopharyngitis.  It 
furnishes,  in  addition,  the  chief  source  of  the  thick  mucous  or  muco- 
purulent  secretion  which  drops  into  the  threat  below,  and  gives  rise  to 
the  disagreeable  desire,  and  even  the  necessity,  of  the  patient's  incessant 
hawking  and  spitting.  Hence,  it  may  be  stated  as  a  fact  that  in  either 
childhood  or  adult  life  the  presence  of  an  adenoid  in  the  nasopharynx 
is  a  constant  menace  to  the  integrity  not  only  of  the  nasopharynx  but 
also  of  the  middle  ear  as  well. 


INFLUENCE    OF   NASAL    AND   NASOPHARYNGEAL   DISEASES 


207 


The  influence  of  the  faucial  tonsils  in  the  causation  of  ear  diseases 
is  much  less  than  that  arising  from  the  presence  of  adenoids  in  the 
vault  of  the  pharynx.  Enlargement  of  the  faucial  tonsils  is  frequently 
accompanied  by  a  corresponding  amount  of  hypertrophy  in  the  vault, 
and  as  a  matter  of  course  when  this  is  the  case,  aural  complications  are 
the  rule.  Even  when  very  greatly  enlarged  the  faucial  tonsils  seldom, 
if  ever,  produce  direct  pressure  upon  the  mouths  of  the  Eustachian 
tubes,  and  in  their  situation  behind  the  oral  cavity  do  not  favor  the 


FIG.   119. — METHOD  OF  MAKING  EXAMINATION  OF  THE  POSTERIOR  XARES  AND  NASOPHARYNX.     (D.  Braden 

Kyle.) 

The  handle  of  the  mirror  should  be  somewhat  lifted  to  bring  the  nasopharynx  into  view.  The  illus- 
tration shows  the  nasopharynx  to  be  free  from  adenoid  hypertrophy.  If  an  adenoid  were  present  it  would 
obstruct  the  view  shown  in  the  upper  part  of  the  mirror,  and  the  upper  turbinates  and  posterior  end  of  the 
vomer  could,  therefore,  not  be  seen. 

suction  of  the  air  from  the  middle  ear  during  each  act  of  deglutition,  as 
in  the  case  when  the  nasopharyngeal  vault  is  filled  with  adenoid  vegeta- 
tions. The  chief  harmful  influence  exerted  upon  the  ear  by  hypertrophy 
of  the  faucial  tonsils  comes,  no  doubt,  from  the  fact  that  the  greatly 
enlarged  glands  seriously  interfere  with  the  normal  contraction  of  the 
faucial  muscles  in  swallowing,  and  hence  from  the  hindrance  they 


208  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

offer  to  the  normal  method  of  opening  the  Eustachian  tube  and  con- 
sequently to  the  ventilation  of  the  middle  ear.  The  presence  of  diseased 
tonsils  also  sets  up  a  chronic  pharyngitis  coincident  with  increased 
and  vitiated  secretion  of  the  glands  of  the  pharynx  and  nasopharynx; 
and  this,  as  has  already  been  seen,  is  productive  of  middle-ear  disease. 

Nasal  obstruction  due  to  the  presence  of  inflammatory  or  new 
growths  may  affect  the  auditory  mechanism  in  much  the  same  manner 
as  adenoids.  When  the  obstruction  is  situated  in  the  anterior  portion 
of  the  nasal  chamber,  a  rarefaction  of  the  air  in  the  nasopharyngcal 
space  follows  as  a  result  of  the  passive  interference  with  the  free  admis- 
sion of  air  to  the  cavity,  whereas  if  the  growth  occurs  posteriorly  and  ex- 
tends backward  into  the  nasopharyngeal  space,  it  will  not  only  cut  off 
the  free  ventilation  of  the  nasopharynx,  but  will  in  addition  mechanically 
hinder  the  action  of  the  palatal  muscles,  and  will  therefore  interfere 
with  the  normal  method  of  opening  the  Eustachian  tube.  Partial 
blocking  of  the  nostrils  from  any  cause  necessitates  an  increased  exertion 
on  the  part  of  the  patient  in  cleansing  the  nose  by  blowing,  and  a  too 
vigorous  and  frequent  effort  in  this  direction  sets  up  a  passive  congestion 
of  the  Eustachian  tube  and  middle  ear.  Moreover,  pathogenic  bacteria 
may  also  be  carried  from  the  nasopharynx  to  the  tympanum  by  the 
powerful  air  blasts  which  the  individual  attempts  to  blow  through  the 
partly  obstructed  nose  in  his  efforts  to  clear  the  stuffy  nasal  channels. 

The  dangers  to  which  the  child  with  adenoids  is  submitted  are  very 
greatly  increased  during  an  attack  of  scarlet  fever,  measles,  or  diphtheria. 
Any  one  of  these  diseases  which  might  otherwise  be  quite  mild  and 
harmless  to  the  ear  in  the  case  of  a  child  with  a  normal  throat,  may  run 
a  violent  course,  and  cause  serious  and  extensive  destruction  of  the 
tissues  of  the  ear  in  the  child  whose  upper  respiratory  tract  is  blocked 
with  these  growths.  Undoubtedly  diphtheria  frequently  begins  in  the 
diseased  nasopharynx  several  hours  before  it  makes  its  appearance  in 
the  fauces,  where  it  is  most  commonly  first  detected.  The  author  has 
had  an  opportunity  to  examine  several  cases  of  this  disease  in  which 
there  was  present  a  well-formed  diphtheritic  membrane  covering  the 
adenoid  tissue  in  the  vault  of  the  pharynx  at  a  time  when  absolutely 
no  evidence  of  the  disease  existed  in  any  part  of  the  oropharynx.  The 
large  extent  of  surface  provided  by  the  exterior  of  a  well-formed  adenoid, 
together  with  that  of  all  the  numerous  and  deep  fissures  between  its 
various  lobes,  furnishes  an  extensive  field  for  the  deposit  of  such  a 
membrane,  as  well  as  for  the  absorption  of  the  pathogenic  products 
of  the  disease  which  are  produced  in  the  crypts  and  upon  the  gland. 

During   the    angina   which   accompanies   scarlatina,  measles,    and 


INFLUENCE   OF   NASAL   AND   NASOPHARYNGEAL    DISEASES  209 

tonsillitis  the  streptococcus  pyogenes  is  very  frequently  and  perhaps 
always  present.1  The  well-known  fact  that  the  occurrence  of  one  of 
these  diseases  is  a  menace  to  the  integrity  of  the  hearing  apparatus  is 
explained  on  the  following  grounds:  (a)  During  the  inflammatory 
state  of  the  tonsils  and  nasopharyngeal  adenoids  which  accompanies 
the  height  of  the  particular  disease,  there  is  a  rapid  increase  of  the 
normal  number  of  streptococci,  pneumococci,  or  other  pathogenic 
bacteria  which  inhabit  these  structures.  (&)  The  mechanical  stimulus 
produced  by  the  presence  of  the  pharyngeal  growth,  together  with  the 
inflammatory  action  taking  place  within  these  glandular  structures, 
induces  the  secretion  of  a  large  amount  of  ropy  mucus  in  the  naso- 
pharynx, of  which  the  patient  rids  himself  by  blowing  the  nose  and 
hawking,  (c)  The  mucous  lining  of  the  Eustachian  tube,  together 
with  that  of  the  tympanic  cavity,  is  more  or  less  congested  and  swollen 
in  common  with  that  of  the  entire  upper  air  tract,  and  is  therefore  in  a 
state  receptive  to  inflammatory  action  so  soon  as  the  necessary  bacteria 
are  added,  (d)  Owing  to  the  blocking  of  the  nose  and  nasopharynx 
by  the  inflamed  adenoids  and  tonsils,  blowing  the  nose  for  the  purpose 
of  dislodging  the  infected,  ropy  mucus  becomes  difficult,  and  the 
powerful  efforts  of  the  patient  to  clear  the  upper  air  tract  often  drives 
the  bacteria-laden  mucus  through  the  Eustachian  tube  into  the  middle 
ear,  where  violent  infection  at  once  ensues  and  suppuration  and  tissue 
destruction  are  the  inevitable  results.  It  must  be  admitted  that  bacteria 
may  find  their  way  into  the  middle  ear  by  means  other  than  that  pro- 
vided by  the  patient  when  blowing  the  nose,  since  the  inflammation 
accompanying  these  diseases  in  children  too  young  to  perform  this  act 
must  be  otherwise  explained.  In  infancy  and  early  childhood  the 
Eustachian  tube  is  shorter  and  wider  in  proportion  than  in  adults  and 
the  bacteria,  no  doubt,  find  their  way  through  such  a  channel  much 
more  readily  than  would  be  possible  in  the  long  narrow  tube  of  the 
grown  individual. 

Children  usually  do  not  expectorate  the  secretions  which  form  in 
the  nasopharynx  or  pharynx  until  the  age  of  puberty,  and  hence  the 
large  amount  of  mucopurulent  material  that  forms  in  the  upper  air 
tract,  largely  as  a  result  of  the  presence  of  the  adenoid,  enters  the  stomach, 
where  it  interferes  with  the  digestion,  and  consequently  with  the  general 
nutrition  of  the  child.  Partly  for  this  reason  and  partly  from  the  fact 
that  oxygenation  of  the  blood  is  imperfectly  accomplished,  owing  to  the 

1  Rudinger,  Journal   Amer.   Med.    Assoc.,  Oct.   13,   1906,  found  the  streptococcus 
pyogenes  present  in  all  of  the  75  cases  examined.     In  measles  it  was  found   present  in 
9  out  of  14  cases,  and  it  was  found  always  to  predominate  in  cases  of  tonsillitis. 
14 


2IO  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

difficulty  with  which  respiration  is  carried  on,  the  physical  condition  of 
these  cases  is  usually  impaired.  As  a  result,  any  aural  or  other  affection 
of  the  child  yields  slowly  or  not  at  all  to  treatment  until  first  the  diseased 
condition  of  the  throat  is  restored  to  normal. 

Diagnosis. — The  diagnosis  of  adenoids  may  easily  be  made  in  most 
typic  cases.  The  peculiar  expression  of  the  eyes,  the  obliterated  lines 
about  the  alae  nasi,  the  open  mouth,  dead  voice,  noisy  respiration,  and 
history  of  frequent  cold-taking,  earache,  dulness  of  hearing  or  aural 
discharge,  form  diagnostic  symptoms  that  point  unmistakably  to  this 
condition.  There  is,  however,  another  very  numerous  class  of  adenoid 
children  in  which  the  symptoms  are  much  less  marked,  although  the 
adenoid  mass,  when  removed,  seems  quite  large  enough  to  have  filled 
the  nasopharyngeal  space  completely.  By  means  of  a  careful  examina- 
tion of  a  child  of  this  class  it  will  usually  be  possible  to  detect  a  majority 
of  the  symptoms  that  attend  the  typic  case,  but  in  a  less  marked 
degree.  The  child  is  a  mouth  breather,  but  keeps  his  lips  so  approxi- 
mated that  only  a  chink  is  left  through  which  the  air  passes.  The 
breathing  is  moderately  noisy  during  sleep,  and  the  child  is  usually  so 
restless  that  the  bedclothing  is  frequently  displaced.  Head  colds 
are  frequent,  earaches  and  aural  discharges  are  common,  and  a  varying 
degree  of  deafness  may  usually  be  detectd  when  the  function  is  carefully 
examined  in  this  respect.  Parents  will  frequently  state  that  the  child 
has  the  habit  of  making  a  low,  snorting,  or  puffing  noise  through  the  nose. 
The  reason  for  the  performance  of  this  by  the  patient  is  explained  by 
the  fact  that  bridles  of  thick  ropy  mucus  collect  upon  the  surface  of 
the  adenoid,  stretch  from  it  into  the  choanae,  and  lie  as  a  weight  upon 
the  superior  surface  of  the  soft  palate.  The  child  makes  the  puffing, 
blowing  noise  through  the  nostrils  in  order  to  displace  the  mucus  and 
thus  give  momentary  freedom  of  respiration  as  well  as  relief  from  the 
load  of  mucus  which  lies  upon  the  palate.  The  history  of  the  child 
constantly  making  such  a  noise  forms  one  of  the  most  reliable  sub- 
jective symptoms  of  adenoids. 

A  physical  examination  is,  however,  entirely  necessary  to  a  positive 
diagnosis  in  many  cases.  If  the  child  is  past  six  years  of  age,  if  the 
examiner  can  obtain  its  entire  confidence,  and  if  the  throat  be  not  over- 
sensitive tc  the  instruments,  the  adenoid  may  be  seen  by  postrhinoscopic 
examination  by  means  of  a  suitable  tongue  depressor  (Fig.  119),  small 
postrhinoscopic  mirror,  and  reflected  light.  It  is  also  frequently  possi- 
ble to  see  an  adenoid  by  means  of  an  anterior  rhinoscopic  inspection. 
The  nostrils  of  adenoid  children  are  frequently  quite  wide,  and,  when 
such  is  the  case,  if  a  small  quantity  of  a  solution  of  adrenalin  chlorid 


INFLUENCE   OF   NASAL    AND    NASOPHARYNGEAL    DISEASES          21 J, 

(i :  1000)  be  sprayed  into  each,  and  the  examination  be  continued 
five  minutes  later,  it  will  be  found  that  the  tissues  of  the  lower  meatus 
axe  greatly  shrunken  and  that  the  adenoid  mass  can  be  seen  distinctly 
through  the  widely  open  nasal  fossae.  In  such  instances  it  is  often 
necessary  to  touch  the  adenoid  with  a  probe  in  order  to  be  sure  that  it  is 
hypertrophied  lymphoid  tissue  and  not  the  posterior  wall  of  the  naso- 
pharynx, which  is  seen  through  the  nostril.  If  the  probe  is  to  be  used 
for  this  purpose  a  4  per  cent,  solution  of  cocain  should  be  sprayed 
into  each  nostril  at  the  same  time  that  the  adrenalin  solution  is  used. 
When  the  mucous  membrane  of  the  nostril  is  thus  anesthetized  and 
shrunken,  a  delicate  cotton-tipped  applicator  can  be  passed  through 
the  dilated  nostril,  into  the  nasopharynx,  and  the  adenoid  mass  can  be 
lifted  from  side  to  side  or  moved  upward  by  the  instrument,  and  the 


FIG.  120. — CONVENIENT,  EASILY  STERILIZABLE  TONGUE  DEPRESSOR. 

diagnosis  can  thus  be  made  with  certainty.  When  the  applicator  is 
withdrawn,  it  will  be  found  that  if  adenoids  were  present,  the  cotton 
on  the  tip  of  the  applicator  is  stained  with  blood,  even  though  the  gen- 
tlest possible  manipulation  was  made,  because  the  epithelial  covering 
of  an  adenoid  is  always  delicate,  and  the  ease  with  which  it  bleeds  is, 
therefore,  a  good  diagnostic  sign  of  its  presence. 

In  case  the  examiner  is  not  able  to  see  the  growth  by  either  of  the 
above  methods,  the  index-finger  may  be  inserted  into  the  nasopharyngeal 
space  and  the  growth  be  detected  by  actually  feeling  it  in  this  location. 
Before  proceeding  with  this  method  the  examining  finger  should  be 
thoroughly  scrubbed  and  sterilized,  since  otherwise  the  child  might 
be  infected  and  serious  consequences  result.  The  child  is  then  placed 
horizontally  across  the  lap  of  an  assistant  with  its  head  toward  the 
examiner  and  hanging  somewhat  downward.  The  examiner  places 


212  THE    PRINCIPLES   AND    PRACTICE    OF   OTOLOGY 

the  back  of  the  head  in  the  palm  of  his  left  hand,  while  the  fingers  of 
the  same  hand  grasp  the  child's  cheek  and  push  it  between  the  teeth  in 
order  to  prevent  any  mishap  from  biting  while  the  examination  proceeds. 
The  child's  head  being  thus  supported,  the  sterilized  finger  is  quickly 
inserted  behind  the  soft  palate,  is  carried  to  the  vault  of  the  nasopharynx, 
and  is  swept  from  side  to  side  in  order  to  make  certain  the  condition 
of  this  cavity.  In  childhood  the  adenoid  mass  feels  soft  to  the  touch, 
and  owing  to  the  struggles  of  the  child  at  the  instant  and  also  the  vigor- 
ous contraction  of  the  soft  palate  around  the  examining  finger,  the 
contracted  palate  may  be  easily  mistaken  for  an  adenoid.  If  the  tissue 
in  the  vault  of  the  pharynx  feels  hard,  and  if  the  posterior  end  of  the 
septum  can  be  made  out  over  its  entire  height,  it  is  probable  that  no 
adenoids  are  present,  whereas,  if  the  whole  vault  seems  filled  with  a  soft, 
though  somewhat  resilient  structure,  the  diagnosis  of  adenoids  may  be 
made.  After  its  withdrawal  the  end  of  the  examining  finger  should 
be  inspected  and  also  the  posterior  wall  of  the  child's  pharynx.  If 
blood  be  found  on  both,  and  no  violence  was  done  during  the  insertion 
of  the  examining  finger,  the  bleeding  furnishes  additional  evidence  of 
the  presence  of  the  adenoid.  This  method  of  diagnosis  requires  con- 
siderable experience  on  the  part  of  the  physician  before  the  information 
gained  by  it  can  be  considered  reliable.  Rude  manipulation  during 
such  an  examination  is  not  essential  and  is  never  justifiable. 

Treatment. — Medical  measures  by  internal  administration  or 
when  applied  locally  to  the  lymphatic  enlargement  have  little  or  no 
effect  on  the  removal  or  lessening  in  size  of  enlarged  adenoids  or  tonsils 
even  when  this  mode  of  treatment  is  continued  over  a  prolonged  period.1 
Their  removal  should,  therefore,  be  accomplished  by  surgical  means,  and 
at  the  earliest  convenient  period  after  their  presence  is  discovered.  When 
both  the  faucial  tonsils  and  nasopharyngeal  adenoids  are  simultaneously 
enlarged,  all  three  of  the  glands  may,  and  usually  should,  be  removed  at 
the  same  operation.  The  question  as  to  whether  or  not  a  general  anes- 
thetic should  be  employed  during  an  adenoid  operation  is  one  to  be  deter- 
mined largely  by  whether  or  not  the  tonsils  are  imbedded — the  "sub- 
merged" tonsil  of  Pynchon — and  as  to  whether  or  not  the  child  has  a 
reasonable  amount  of  self  control.  The  experience  and  training  of 
the  operator  have  much  to  do  with  the  question  of  the  employment  of 

1  The  author  once  treated  20  cases  of  greatly  enlarged  tonsils  and  adenoids, 
each  for  a  period  of  six  months.  Solutions  of  iodin  and  iodid  of  potassium  in  glycerin 
were  applied  to  the  hypertrophied  tissues  three  times  a  week,  and  potassium  iodid  was 
administered  internally  three  times  a  day.  At  the  conclusion  of  the  course  of  treatment 
no  appreciable  difference  was  noticeable  in  the  condition  of  any  case,  and  it  became 
necessary  to  remove  both  adenoids  and  tonsils  surgically. 


INFLUENCE    OF    NASAL    AND    NASOPHARYNGEAL    DISEASES 


213 


a  general  anesthetic  or  of  operating  under  cocain  anesthesia.  Un- 
doubtedly either  method  may  be  followed  with  equal  success  by  those 
who  have  been  trained  to  do  the  operation  thoroughly  by  either  the  one 
or  the  other  plan.  However,  the  element  of  danger  arising  from  general 
anesthetics,  when  administered  for  this  particular  class  of  surgery, 


FIG.  121. — POSITION  OF  PATIENT  FOR  THE  REMOVAL  OF  ADENOIDS  UNDER  A  GENERAL  ANESTHETIC. 

In  this  position  the  blood  flows  from  the  nostrils  and  tnus  lessens  the  danger  of  the  patient  inhaling  it 
into  the  larynx.  It  is  often  preferable  and  frequently  necessary  to  turn  the  patient  upon  one  or  the  other  side. 
Operations  of  this  nature  under  general  anesthesia  are  best  performed  by  means  of  a  curet  with  a  bonnet  (Fig. 
124),  or  with  adenoid  forceps,  (Fig.  123),  since  by  either  of  these  instruments  the  detached  hypertrophy  is  im- 
mediately withdrawn,  and  danger  from  its  presence  in  the  throat  is  thereby  avoided. 

should  not  be  forgotten,  since  several  deaths,  chiefly  from  chloroform, 
have  been  reported.1  Nitrous  oxid,  ethyl  chlorid,  and  somnoform  have 
been  extensively  used  during  adenoid  and  tonsil  operations,  but  their 
effect  is  of  such  short  duration  that  unless  the  operator  is  very  rapid, 

1Hinkel,  Laryngoscope,  July,  1898,  reported  18  deaths  from  chloroform  anesthesia 
occurring  during  adenoid  operations  between  the  years  1892  and  1898.  Hinkel  states 
that  the  habitus  lymphaticus,  of  which  hypertrophied  tonsils  and  adenoids  constitute  a 
part,  renders  the  child  particularly  susceptible  to  death  from  chloroform. 


214  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

has  first-class  assistance,  and  loses  no  time  after  the  operation  is  begun, 
the  patient  is  often  awake  before  the  work  is  satisfactorily  completed,  in 
which  case  a  second  administration  of  the  gas  is  necessary.  Moreover, 
these  latter  anesthetics  do  not  thoroughly  relax  the  palate,  and  hence 
the  manipulation  of  instruments  in  the  nasopharynx  is  more  difficult 
than  when  either  chloroform  or  ether  is  employed. 

When  a  general  anesthetic  is  necessary,  ether  should  usually  be 
administered  because  of  its  greater  safety.  It  is  necessary  to  prepare 
the  patient  by  administering  a  cathartic  on  the  previous  day,  allowing 
only  a  light  diet  on  this  day,  and  no  food  whatever  on  the  morning  of 
the  operation,  because  undigested  food  in  the  stomach  is  sure  to  be 


FIG,  122.— PYNCHON'S  MOUTH  GAG. 

vomited,  and  this  occurrence  during  throat  operations  not  only  intro- 
duces an  unnecessary  element  of  danger  but  also  greatly  hinders  the 
progress  of  the  operation. 

When  anesthetized  the  child  is  laid  upon  a  narrow  table  with  its 
head  hanging  down  over  the  edge  (Fig.  121).  A  mouth-gag  (Fig.  122) 
is  inserted,  the  mouth  is  thereby  widely  opened,  and  the  instrument  is 
held  in  place  by  an  assistant,  who  also  supports  the  patient's  head  in 
any  desired  position.  In  cases  where  both  the  faucial  tonsils  and  adenoids 
are  to  be  removed  at  one  operation,  it  is  easiest  to  remove  the  lower 
glands  first,  for  the  reason  that  if  the  adenoid  is  first  removed  the  very 
considerable  flow  of  blood  which  results  will  so  obscure  a  view  of  the 
isthmus  of  the  fauces  as  to  make  it  difficult  to  see  with  accuracy  the 
necessary  steps  of  the  subsequent  tonsil  ablation.  The  patient's  throat 
is  illuminated  by  the  reflected  light  of  a  head-mirror  (Fig.  89)  worn 
by  the  operator.  The  tongue  is  depressed  by  an  assistant,  whose  duty 


INFLUENCE    OF   NASAL   AND    NASOPHARYNGEAL   DISEASES  215 

it  will  also  be  to  mop  blood  from  the  throat  when  necessary  as  the 
work  progresses. 

Tonsils  should  always  be  removed  deeply  enough  to  include  the 
bottom  of  all  the  tonsillar  crypts.  Therefore,  if  the  gland  is  imbedded 
or  "submerged,"  a  satisfactory  operation  can  only  be  done  after  it 
has  been  dissected  loose  to  an  extent  that  will  permit  the  free  motion 
of  the  tonsil  when  it  is  seized  and  traction  is  made  upon  it  with  a  ten- 
aculum.  Several  forms  of  tonsil  knives  are  advocated  for  loosening  the 
adhesions;  the  author  uses  the  ones  devised  by  Makuen.  The  dis- 
section is  made  by  seizing  the  gland  in  the  teeth  of  a  double  tenaculum 
and  making  sufficient  traction  upon  it  to  lift  the  gland  from  its  bed, 
and  thus  demonstrating  the  points  that  need  further  loosening.  The 


FIG.  123. — QUINLAN'S  ADENOID  FORCEPS. 

tonsil  knife  is  used  first  to  sever  all  bands  between  the  anterior  pillar 
and  the  tonsil,  then  the  gland  is  pulled  forward  and  downward  and 
all  attachments  in  the  supratonsillar  fossae  are  cut,  after  which  traction 
is  made  outward  and  the  knife  separates  the  tonsil  from  the  posterior 
pillar.  The  opposite  tonsil  is  dealt  with  in  an  exactly  similar  manner. 
Each  gland  is  then  quickly  removed  by  means  of  the  tonsillotome 
(see  Fig.  126),  the  tonsil  snare,  or  the  guillotine  ecraseur.  If  the 
gland  contains  a  large  amount  of  connective  tissue,  as  is  usually  the 
case  after  repeated  attacks  of  tonsillitis,  and  in  adult  life,  the  snare 
or  ecraseur  should  be  chosen  because  of  their  efficiency  and  also  be- 
cause less  hemorrhage  follows  their  use,  whereas,  if  the  patient  is  quite 
young  and  the  gland  is  soft  and  protrudes  without  adhesions,  the  ton- 
sillotome is  equally  safe  and  effective.  The  sharp  bleeding  which  occurs 


2l6  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

for  a  short  time  after  the  tonsil  ablation  often  necessitates  an  interruption 
of  the  operation,  during  which  time  the  patient's  head  is  lowered  suffi- 
ciently to  permit  the  blood  to  flow  from  the  nose  and  mouth,  and  thus 
obviate  the  possibility  of  its  entering  the  larynx. 

The  removal  of  the  adenoid  is  then  accomplished  either  by  the  use 
of  the  adenoid  forceps  (Fig.  123),  the  curet  (Fig.  124),  or  by  the  two 


A  B  c 

FIG.  124. — ADENOID  CURETS,  ONE  WITH  BASKET  AND  HOOKS  TO  CATCH  THE  GROWTH  WHEN  SEVERED, 

AND  THUS  PREVENT  THE  POSSIBILITY  OF  ITS  DROPPING  INTO  THE  LARYNX. 

The  basket  is  especially  valuable  when  operating  under  a  general  anesthetic.     The  exact  shape  and  dimensions 
of  these  curets  are  shown  in  Fig.  127,  b. 

combined.  When  forceps  are  employed,  the  operator  stands  at  the 
patient's  head,  his  left  forefinger  is  passed  behind  the  soft  palate  as  far 
as  the  vault,  and  is  kept  in  the  nasopharynx  and  used  as  a  guide  so  long 
as  it  is  thought  necessary  to  reintroduce  the  adenoid  forceps.  The 
forceps  is  introduced  while  closed,  passing  along  the  finger  as  a  guide, 
and  when  the  vault  is  reached,  it  is  opened  as  widely  as  the  cavity  of 
the  nasopharynx  will  permit  in  order  that  the  largest  possible  grasp 


INFLUENCE   OF    NASAL   AND  NASOPHARYNGEAL    DISEASES          217 

of  the  growth  may  be  secured.  After  grasping  the  growth  firmly  between 
the  jaws  of  the  instrument,  a  slight  rotary  motion  is  given  the  handle, 
and  thus  a  large  mass  of  the  adenoid  is  torn  and  bitten  away  from  its 
attachment,  and  withdrawn  from  the  throat  securely  fixed  by  the  blades. 
The  forceps  is  quickly  reintroduced  and  the  process  repeated  until  the 
examining  finger  no  longer  detects  any  considerable  portion  of  the 
growth  in  any  part  of  the  nasopharynx.  The  adenoid  curet  may  then  be 
inserted  into  the  nasopharynx  and  carried  forward  against  the  upper 
posterior  end  of  the  vomer,  after  which  it  is  caused  to  sweep  the  entire 
vault  of  the  nasopharynx  in  such  a  way  as  to  sever  any  remnant  of  the 
adenoid  that  may  have  escaped  the  forceps. 

The  adenoid  curet  (Fig.  124)  is  of  itself  entirely  sufficient  to  com- 
pletely remove  the  adenoid  mass.  Unless,  however,  some  means  are 
provided  by  which  the  severed  gland  can  be  withdrawn  from  the  throat 
along  with  the  curet,  there  is  some  danger  of  its  finding  its  way  into 
the  larynx  and  producing  asphyxiation.  Therefore,  when  the  curet 
alone  is  depended  upon,  an  instrument  should  be  selected  which  is 
provided  with  hooks  and  a  basket  (Fig.  124,  A),  which  provides  for  the 
certain  withdrawal  of  the  severed  growth.  Sharp  bleeding  follows  the 
removal  of  an  adenoid,  but  this  persists  only  for  one  or  two  minutes, 
and  it  is  only  necessary  to  allow  the  patient's  head  to  remain  lowered 
until  this  has  subsided  and  the  patient  has  recovered  consciousness 
sufficiently  to  expectorate  the  blood.  The  mouth-gag  should  be  removed 
just  as  soon  as  the  operation  is  completed. 

The  author  advocates  the  performance  of  a  large  majority  of  all 
tonsil  and  adenoid  operations  with  the  employment  of  only  a  local 
anesthetic.  In  cases  of  children,  where  the  faucial  tonsils  are  not  im- 
bedded, both  tonsils  and  adenoids  can  be  completely  removed  in  a  few 
seconds.  The  pain,  although  considerable,  is  not  severe  or  of  long 
duration,  and  the  danger  and  nausea  attendant  upon  general  anesthesia 
operations  are  entirely  eliminated.  When  the  operation  is  undertaken 
under  a  local  anesthetic,  a  carefully  planned  and  skillfully  executed 
technic  is  necessary  to  a  successful  performance.  A  10  per  cent, 
solution  of  cocain  is  applied  by  means  of  a  cotton-tipped  probe  around 
the  base  of  each  tonsil  and  to  the  nasopharyngeal  space.  This  may 
be  repeated  one  or  more  times  in  the  succeeding  five  minutes.1  When 

1  The  cotton  applicator  should  not  be  dripping  wet  with  the  cocain  solution,  since 
the  contraction  of  the  palatal  muscles  around  it  when  in  the  nasopharynx  will  squeeze 
the  solution  out,  the  patient  will  swallow  it,  and  toxic  symptoms  may  result.  Cocain 
solutions  should  not  be  sprayed  into  the  pharynx  or  nasopharynx  previously  to  operations 
upon  the  throat.  It  is  more  satisfactory  and  safer  to  apply  the  drug  directly  to  the  spot 
to  be  anesthetized,  and  in  stronger  solution  than  could  be  safely  used  in  spraying. 


218 


THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


the  parts  are  sufficiently  anesthetized,  an  assistant  holds  the  child 
upright  in  his  lap,  the  patient's  legs  are  placed  between  the  knees  of  the 
assistant,  where  they  are  firmly  held,  the  child's  arms  are  placed  along 
its  sides  and  across  its  lap,  and  the  assistant  locks  the  fingers  of  his 
own  hands  over  them.  The  child's  head  rests  upon  the  left  shoulder 
of  the  assistant,  and  a  second  assistant  grasps  the  head  on  either  side 
and  supports  it  somewhat  vise-like.  In  this  position  the  child  is  held 
absolutely  quiet,  and  cannot  interfere  with  the  operator  at  any  period 


FIG.  125. — METHOD  OF  OPERATING  FOR  ADENOIDS  UNDER  LOCAL  ANESTHESIA. 

The  correct  size  and  shape  of  the  curet  to  be  used  is  shown  in  Fig.  127.     The  position  of  the  curet  in  the 
nasopharynx  is  shown  in  Fig.  128. 

of  the  operation  (Fig.  125).  This  position,  which  must  be  absolutely 
maintained  by  the  assistants,  is  entirely  essential  to  rapid  and  certain 
results,  and  no  operator  should  undertake  the  performance  of  this 
class  of  surgery  unless  he  has  at  hand  the  assistance  above  described. 

The  faucial  tonsils  are  first  removed  by  means  of  the  Mackenzie 
tonsillotome  (Fig.  126).  The  assistant  who  supports  the  child's  head 
allows  two  fingers  to  extend  under  the  angle  of  first  the  right  jaw  and 
then  the  left,  making  external  pressure  over  the  seat  of  the  tonsil  and 
forcing  it  somewhat  inward  at  the  instant  the  operator  is  ready  to 


INFLUENCE    OF   NASAL   AND    NASOPHARYNGEAL   DISEASES 


219 


remove  it.  The  operator  requests  the  child  to  open  its  mouth,  then 
using  the  flat  blade  of  the  tonsillotome  as  a  tongue  depressor,  slips  it 
quickly  over  first  the  right  tonsil  and  then  the  left,  and  removes 
each  deeply  before  the  child  is  scarcely  aware  of  what  is  taking  place. 
Without  a  second's  delay,  and  therefore  before  the  child  begins  to 
strangle  from  the  free  outpouring  of  blood  from  the  excised  tonsils,  a 
curet  of  proper  width  and  shape  is  inserted  behind  the  palate  and  the 
adenoid  is  severed  by  a  single  sweep  of  the  knife  over  the  vault.  The 
child's  head  is  then  held  forward,  he  expectorates  the  adenoid  into  a 


FIG.  126. — SET  OF  MODIFIED  MACKENZIE  TONSILLOTOMES. 

The  use  of  these  instruments  is  recommended  only  in  cases  where  the  tonsils  project  well  from  their  bases. 
When  the  glands  are  imbedded,  even  partially,  they  must  be  loosened  by  dissection  and  are  then  best  removed 
by  means  of  the  cold  wire  snare  or  scissors. 

basin,  and  blood  pours  from  the  nostrils  and  mouth  for  a  minute  or 
more. 

The  instruments  to  be  used  in  any  given  case  for  the  purpose  of 
removing  hypertrophied  tonsils  and  adenoids  must  be  intelligently 
selected  at  a  previous  examination.  The  tonsillotome  should  be  of 
such  size  that  its  fenestra  will  fit  snugly  over  each  tonsil.  The  width 
of  the  adenoid  curet  must  be  governed  by  the  width  of  the  child's  naso- 
pharyngeal  space,  and  therefore  this  point  must  be  noted  with  as  much 
accuracy  as  possible,  for  if  a  curet  be  used  which  is  too  small  it  is  obvious 


22O 


THE    PRINCIPLES   AND    PRACTICE    OF   OTOLOGY 


that  only  a  portion  of  the  adenoid  can  be  secured  at  one  cut,  and  the 
operation  must  therefore  be  repeated  under  difficulties.  The  fenestra 
should  be  of  sufficient  width  in  each  case  to  require  very  gentle  crowd- 
ing of  the  shanks  upon  the  lateral  walls  of  the  nasopharynx  when  the 
curet  is  inserted.  If  an  instrument  of  proper  size  and  shape  be  selected 
it  is  always  possible  to  cut  away  the  entire  growth  at  one  sweep  of 
the  curet  (Fig.  128). 

In  the  removal  of  an  adenoid  by  this  method,  the  child's  head  must 
be  held  squarely  toward  the  operator.     The  operator  must  insert  the 


FIG.  127. — SHOWING  THE  DISTAL  FACES  OF  ADENOID  CURETS.    (Actual  size.) 

A,  improper  width  and  shape  of  fenestra;.  With  this  form  of  curet  successful  removal  of  the  adenoid,  en 
masse,  is  impossible.  B,  curets  of  proper  width  and  shape  of  fenestr.-e.  Note  that  the  narrow  shanks  occupy 
but  a  minimum  of  lateral  space,  and  that  the  width  of  the  cutting  blade  takes  up  but  the  smallest  anteroposterior 
space.  A  profile  view  of  the  curvature  of  the  shank  is  shown  in  Fig.  127.  When  selected  according  to  the 
width  of  the  patient's  nasopharynx  it  is  possible  with  this  curet  to  remove  the  adenoid  en  masse  at  one  sweep 
of  the  instrument. 

instrument  so  that  it  will  be  kept  exactly  in  the  median  line  of  the 
patient's  nasopharynx.  So  soon  as  the  curet  is  inserted  behind  the  soft 
palate  it  must  be  pressed  upward  to  the  vault,  and  forward  against 
the  superoposterior  portion  cf  the  vomer.  Should  the  operator  make 
a  sweep  of  the  instrument  before  the  cutting  blade  is  known  to  be  in 
this  position,  only  a  portion  of  the  growth  will  be  severed.  Should  he 
begin  this  "sweep"  at  the  point  shown  in  Fig.  128,  and  hug  the  vault 
of  the  pharynx  continuously  throughout  its  course,  the  whole  growth 
will  most  certainly  be  removed  en  masse  (Figs.  129  and  130),  provided 
the  curet  has  been  properly  selected  and  is  of  sufficient  width. 


221 


Following  an  operation  by  any  method,  little  subsequent  treatment 
is  necessary  further  than  to  keep  the  patient  quiet  for  from  two  days 


FIG.  128. — PROPER  POSITION  OF  ADENOID  CURET  IN  THE  REMOVAL  OF  HYPERTROPHY  BY  ONE  SWEEP  OF 

INSTRUMENT. 

Patient  in  upright  position.     Curet  must  be  of  dimensions  ample  to  surround  entire  growth.     See  Fig.  127. 
Note  that  the  mouth  is  open  to  its  fullest  extent  and  that  the  uvula  and  soft  palate  are  crowded  well  upward. 


FIG.  129. — LARGE  ADENOID  REMOVED  EN  MASSE 
BY  ONE  SWEEP  OF  THE  CURET. 

Type  of  growth  when  removed  by  this  method. 
Actual  size ;  child  six  years  old. 


FIG.  130. — ADENOID  REMOVED  BY  CURET  FROM 

CASE  SHOWN  IN  FIG.  117. 

Actual  size. 


to  a  week.     After  removal  of  the  faucial  tonsils,  an  astringent  and 
antiseptic  solution  is  prescribed: 


222  THE   PRINCIPLES    AND    PRACTICE   OF   OTOLOGY 

Ii.  Tr.  ferri  chlorid,  31  j; 

Glycerin,  ad.  q.s.  ^iij. — M. 

Sig.  Half-teaspoonful    to   be  swallowed  every  two  hours  first  day,  every  four  hours 
afterward.     An  appropriate  prescription  for  children  too  young  to  gargle. 

Following  tonsillectomy,  the  character  of  the  food  must  be  regulated. 
During  the  first  day  iced  milk  should  constitute  the  sole  nourishment. 
Afterward,  soups,  custards,  boiled  rice,  and  the  softest  food  in  general 
should  be  directed. 


ACUTE    AFFECTIONS    OF    THE    MIDDLE    EAR 

PRELIMINARY    REMARKS 

IN  this  division  of  the  work  are  included  the  diseases  of  the  mem- 
brana  tympani,  acute  catarrhal  congestion  of  the  Eustachian  tube 
and  tympanic  cavity,  the  acute  catarrhal,  and  the  acute  suppurative 
inflammations  of  the  middle  ear.  In  all  that  pertains  to  the  causation, 
symptoms,  and  pathology  of  these  several  diseases,  the  Eustachian  tube 
must  be  considered  as  forming  an  important  part  of  the  middle  ear,  as, 
indeed,  must  also  the  mastoid  antrum  and  the  mastoid  cells.  Therefore 
in  the  study  of  the  diseases  incident  to  the  conducting  portion  of  the 
organ  of  hearing,  the  student  should  have  a  broader  conception  of 
the  term  "middle  ear"  than  has  heretofore  obtained,  and  should  always 
think  of  it  as  including  not  only  the  tympanic  cavity  but  also  the  Eus- 
tachian tube,  and,  at  least  in  a  very  closely  associated  way,  the  accessory 
cavities  of  the  mastoid  antrum  and  mastoid  cells.  With  this  conception 
of  the  middle  ear,  the  rather  considerable  extent  of  mucous  membrane, 
beginning  at  the  nasopharyngeal  orifice  of  the  Eustachian  tube  and 
ending  in  the  mastoid  cells  at  the  tip  of  the  mastoid  process,  will  be 
better  realized  and  the  causation,  pathology, -and  treatment  of  the  several 
affections  of  the  labyrinth  of  cavities  comprising  the  conducting  portion 
of  the  hearing  apparatus  will  undoubtedly  be  better  understood.  The 
environment  of  the  middle  ear,  the  external  auditory  meatus,  the  nose 
and  nasopharynx  should  also  be  more  carefully  studied  in  its  causative 
relations  to  the  aural  diseases  of  this  portion  of  the  ear. 

CHAPTER  XX 

DISEASES  AND  INJURIES  OF  THE  MEMBRANA  TYMPANI 

SINCE  the  membrana  tympani  separates  the  external  from  the  middle 
ear,  and  since  its  inner  surface  or  mucosa  forms  a  portion  of  the  tympanic 
cavity,  while  its  outer  surface  or  dermoid  layer  is  a  continuation  of  the 
skin  of  the  external  meatus,  it  follows  that  the  structure  may  be  affected 
by  diseases  involving  either  the  middle  ear  or  external  auditory  meatus. 
The  drum  membrane  is,  however,  sometimes  affected  independently 
of  any  disease  in  the  neighboring  tissues,  and  it  is  evident  that  when 
this  is  the  case  the  affection  cannot  properly  be  classified  with  the  dis- 
eases of  either  the  external  or  of  the  middle  ear. 

223 


224  THE   PRINCIPLES   AND    PRACTICE    OF   OTOLOGY 

ACUTE    MYRINGITIS 

Acute  myringitis,  or  inflammation  of  the  drum-head,  occurs  as  the 
result  of  infection  or  irritation  of  this  portion  of  the  organ  of  hearing. 
It  usually  results  from  the  entrance  of  cold  water  into  the  ear,  from  the 
exposure  of  the  ear  to  the  direct  action  of  a  severe  cold  wind,  or  from 
the  instillation  of  caustic  or  irritant  fluids  into  the  external  auditory 
canal.  Any  of  the  causes  previously  enumerated  as  productive  of  an 
otitis  externa  may  also  give  rise  to  a  myringitis. 

Symptoms. — The  patient  complains  of  an  earache  which  may  be 
very  severe  or  quite  mild,  of  tinnitus  aurium,  and  of  a  full  stuffy  feeling 
in  the  affected  side  of  the  head.  There  is  little  complaint  as  to  loss  of 
hearing,  since  this  function  is  seldom  seriously  affected.  In  case  the 
patient  is  a  child,  some  fever  and  restlessness  may  accompany  the 
disease. 

The  appearances  upon  otoscopic  examination  are  those  that  are 
characteristic  of  the  earlier  stages  of  inflammatory  affections  of  the 
middle  ear.  The  plexus  of  vessels  along  the  handle  of  the  malleus  is 
first  seen  to  be  injected,  and  then  the  redness  spreads  over  a  portion  or 
the  whole  of  the  membrane.  The  vascular  injection  together  with  the 
swelling  which  takes  place  in  the  structure  of  the  drum  membrane 
itself  soon  obliterates  the  normal  landmarks.  In  the  severest  cases 
small  dark  brown  spots  are  sometimes  seen.  These  are  caused  by 
minute  hemorrhages  into  the  substance  of  the  tympanic  membrane. 
The  exudation  of  serum  or  blood  beneath  the  dermoid  layer,  which 
occasionally  takes  place,  appears  in  the  form  of  dark  blue  or  slightly 
yellowish  blisters  upon  the  surface  of  the  posterosuperior  quadrant. 
If  the  observation  of  the  membrana  is  made  at  a  later  period  no  blisters 
may  be  visible,  but  a  slight  serous  or  bloody  discharge  will  be  found  in 
the  auditory  canal  which  results  from  the  rupture  of  the  blebs  and 
the  subsequent  discharge  of  the  exudate  from  the  denuded  areas.  If 
examined  at  the  end  of  a  week  from  the  onset,  the  drum  membrane  will 
probably  be  found  dry  and  desquamating,  and  sometimes  the  whole 
or  at  least  a  considerable  portion  of  the  entire  dermoid  layer  of  the 
drum-head  is  found  to  have  exfoliated,  and  to  be  lying,  partly  detached, 
at  the  fundus  of  the  auditory  canal.  After  the  removal  of  this  detached 
portion  the  underlying  membrane  may  still  appear  uniformly  red, 
but  of  a  less  intensity  than  at  the  height  of  the  inflammation.  Gradually 
the  drum  membrane  is  restored  to  its  normal  color  and  thickness;  or 
more  rarely  the  disease  may  become  chronic.  Politzer  (Diseases  o]  the 
Ear,  p.  237)  relates  a  case  in  which  there  was  an  abscess  formation  in 


DISEASES   AND    INJURIES   OF   THE   MEMBRANA   TYMPANI  22$ 

the  structures  of  the  drum-head  which  finally  ruptured  into  the  middle 
ear  and  set  up  an  acute  olitis  media. 

Diagnosis. — The  chief  difficulty  lies  in  differentiating  myringitis 
from  acute  otitis  media  of  either  the  catarrhal  or  suppurative  variety. 
The  appearance  of  the  drum  membrane  during  the  otoscopic  examina- 
tion may  be  exactly  the  same  in  each  disease.  The  occurrence  of 
bullae  upon  the  surface  is  more  common  in  myringitis  than  in  otitis 
media.  The  pain,  tinnitus,  and  stuffy  feeling  in  the  head  are  usually 
not  so  severe  in  myringitis  as  in  otitis  media,  and  the  amount  of  deafness 
which  results  from  otitis  media  is  very  much  greater  than  that  which 
occurs  from  myringitis.  Indeed,  it  is  upon  this  point  that  the  diagnosis 
can  be  best  made,  for  in  any  case  in  which  there  is  pain  in  the  ear, 
tinnitus,  and  fulness  in  the  head,  and  in  which  the  drum  membrane 
shows  signs  of  active  inflammation,  if  the  hearing  is  but  slightly  impaired 
the  conclusion  should  be  that  only  an  inflammation  of  the  drum  mem- 
brane is  present,  whereas,  if  more  pronounced  deafness  is  present,  the 
same  is  evidence  of  an  involvement  of  the  cavum  tympani.  Since  a 
discharge  may  occur  as  a  result  of  either  disease,  it  is  important  to 
determine  whether  this  comes  from  the  middle  ear  through  a  perforated 
drum  membrane,  or  whether  it  occurs  from  the  bases  of  the  ruptured 
bullae  which  spring  from  the  membrana  tympani  itself.  This  question 
may  be  settled  by  actually  seeing  the  perforation  during  the  otoscopic 
examination,  but  if  uncertain  concerning  this  point,  politzerization 
or  catheter  inflation  may  be  performed  while  at  the  same  time  the 
examiner  observes  the  drum-head  when,  if  the  perforation  exists,  its 
location  will  be  made  evident  by  the  escape  of  bubbles  of  air  or  fluids 
at  the  site  of  rupture.  Myringitis  may  be  mistaken  for  earache  of  a 
reflex  or  neuralgic  nature  unless  the  physical  examination  of  the  drum 
membrane  is  carefully  made.  In  myringitis  this  membrane  is,  as 
already  stated,  highly  inflamed  and  swollen;  the  landmarks  are  often 
submerged  and  wanting.  When,  however,  the  otalgia  is  due  to  reflex 
causes  the  drum  membrane  usually  has  an  entirely  normal  appearance. 
Moreover,  in  non-inflammatory  earache  the  source  of  the  reflex  pain 
may  be  discovered  in  a  carious  tooth  or  an  ulcerated  throat.  An 
examination  of  the  mouth  and  throat,  including  the  teeth,  should  not 
be  omitted  in  any  questionable  case  of  earache. 

Treatment. — When  seen  at  the  onset,  palliative  measures  should 
be  at  once  instituted.  If  the  pain  is  severe  codein  may  be  administered 
in  £-  or  J-gr.  doses,  and  repeated  every  two  to  four  hours  if  necessary. 
Dry  heat  applied  locally  to  the  ear  by  means  of  the  hot-water  bottle 
is  usually  very  grateful  to  the  patient.  Local  depletion  either  by  means 

15 


226  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

of  the  artificial  or  natural  leech  not  only  relieves  the  pain,  but  if  applied 
early  may  be  classed  as  an  abortive  measure.  A  pledget  of  cotton  of 
proper  size  to  fit  the  meatus  snugly,  if  dipped  in  the  carbolized  glycerin 
solution  (see  p.  256)  and  applied  against  the  drum  membrane  as  hot 
as  can  be  borne,  is  of  undoubted  assistance  in  relieving  both  the  pain 
and  the  feeling  of  fulness  in  the  ear. 

Should  one  or  more  large  blisters  form  in  the  dermoid  layer  of  the 
drum  membrane,  the  same  may  be  incised  with  a  delicate  knife  (Fig.  141). 
Usually,  however,  the  blebs  rupture  almost  immediately  after  they  are 
fully  formed,  thus  rendering  their  incision  unnecessary.  In  case  the 
knife  is  used  to  incise  them,  care  must  be  taken  not  to  penetrate  the 
entire  thickness  of  the  membrana  tympani,  since  this  is  unnecessary 
and  a  deep  incision  might  admit  some  of  the  contents  of  the  bulla  into 
the  drum  cavity,  with  the  result  of  infection  and  subsequent  suppuration 
within  the  cavity.  The  serous  discharge  following  the  spontaneous 
rupture  or  the  incision  of  these  blisters  is  usually  slight  and  promptly 
ceases.  Should  the  areas  occupied  by  the  bases  of  the  blebs  remain 
raw  and  moist,  boric  acid  should  be  insufflated  into  the  external 
auditory  meatus  in  a  quantity  sufficient  to  form  a  thin  coating  over 
the  dermoid  surface  of  the  drum-head.  In  case  the  exudate  persists 
and  becomes  purulent  and  foul  smelling,  the  ear  should  be  frequently 
syringed  with  an  antiseptic  solution,  should  afterward  be  thoroughly 
dried,  and  the  dressing  should  then  be  completed  by  the  insufflation 
of  the  finely  powdered  boric  acid  after  the  manner  just  stated. 

CHRONIC    MYRINGITIS 

Chronic  myringitis  sometimes  persists  as  a  sequel  of  the  acute 
variety.  It  occasionally  accompanies  a  chronic  otitis  externa.  Existing 
as  an  uncomplicated  affection  it  is  rare. 

The  symptoms  of  the  disease  are  a  moderate  foul-smelling  discharge 
from  the  ear  and  an  intense  itching  in  the  depths  of  the  auditory  meatus. 
The  impairment  of  the  hearing  is  not  so  great  as  would  be  indicated 
either  by  the  nature  of  the  discharge  or  the  appearance  of  the  drum 
membrane.  Pain,  fulness  in  the  head,  and  tinnitus  aurium  are  less 
marked  than  in  the  acute  variety.  The  diagnosis  will  be  based  upon 
the  fact  that  the  hearing  is  comparatively  good,  and  that  inflation  of 
the  middle  ear  gives  rise  to  no  perforation  whistle  or  other  evidence  of 
ruptured  drum  membrane. 

The  appearances  of  the  drum  membrane  are  not  diagnostic  of  this 
disease.  The  external  surface  will  be  dull  when  covered  by  an  epider- 
mis that  is  ready  to  exfoliate.  After  exfoliation  the  underlying  mem- 


DISEASES   AND    INJURIES   OF   THE   MEMBRANA   TYMPANI  227 

brane  may  look  thickened,  uniformly  inflamed,  and  moist  with  exudate. 
Politzer  (Diseases  of  the  Ear,  p.  239)  describes  the  occasional  presence 
on  the  drum  membrane  of  small,  light  red  papillary  excrescences,  singly 
or  in  groups,  in  which  latter  instance  the  membrane  has  the  appearance 
of  a  purple  raspberry. 

The  treatment  consists  in  cleansing  the  ear  of  any  irritating  dis- 
charge by  means  of  the  syringe.  Bichlorid  of  mercury  solution  (i :  8000) 
is  best  for  this  purpose.  The  canal  is  then  dried  and  a  mixture  of 
equal  parts  of  finely  powdered  boric  acid  and  oxid  of  zinc  is  insufflated 
by  means  of  the  powder-blower  (Fig.  213).  When  the  membrane  looks 
raw  and  finely  granular  the  alcohol  and  boric  acid  lotion  may  be  instilled 
into  the  ear  in  either  a  pure  or  somewhat  diluted  form.  This  solution 
is  prepared  as  follows: 

H .  Acid,  boracis,  gr.  xx  ; 

Alcoholis,  5J. — M. 

If  there  is  much  odor  to  the  discharge,  mercuric  bichlorid  may  be 
added  to  this  preparation  in  the  proportion  of  i :  8000.  Should  severe 
pain  result  from  the  instillation  of  this  preparation  into  the  ear,  it  should 


FIG.  131. — DELICATE  ALUMINIUM  PROBE.     (Three-fourths  natural  size.) 
Very  useful  as  a  caustic  carrier  in  treatment  of  granulations  and  small  polypi. 

be  diluted  by  the  addition  of  distilled  water,  and  then  gradually  be 
increased  to  full  strength  as  the  patient  acquires  a  better  toleration. 
Should  larger  granulations  be  present  on  the  outer  surface  of  the  mem- 
brane, these  are  best  destroyed  by  fusing  a  minute  bead  of  chromic  acid 
upon  the  end  of  a  very  small  applicator  (Fig.  131),  and  then  touching 
each  granulation  separately  every  third  day  until  all  have  disappeared.1 

1  In  the  local  treatment  of  the  exuberant  granulations,  which  are  frequently  met 
with  in  the  ear,  especially  in  the  chronic  suppurative  aural  affections,  the  application  of 
chromic  acid,  nitrate  of  silver,  or  other  active  caustic  is  often  recommended.  The  student 
should,  therefore,  acquire  the  exact  methods  of  preparing  these  powerful  caustics  so  that 
they  may  be  carried  with  ease,  safety,  and  accuracy  to  the  remotest  portions  of  the  drum 
cavity  and  to  the  most  limited  areas.  The  employment  of  crude  instruments  and 
bungling  methods  in  carrying  these  agents  to  a  definite  spot  in  a  situation  so  deeply  seated 
may  result  in  great  harm  to  the  ear  and  in  intense  and  unnecessary  suffering  to  the  patient. 

The  applicator  which  is  selected  for  carrying  caustic  agents  into  the  middle  ear  should 
be  flexible  and  its  diameter  beyond  the  handle  should  be  exceedingly  small  (Fig.  131). 
If  pure  nitrate  of  silver  is  to  be  used  the  crystals  should  be  melted  in  a  small  platinum 
or  porcelain  receptacle  over  an  alcohol  flame.  The  distal  end  of  the  cold  applicator  is 
then  dipped  into  the  melted  silver,  when  a  thin  pellicle  of  the  caustic  instantly  adheres. 
By  allowing  this  to  cool,  and  then  again  dipping  it,  a  bead  of  silver  of  any  desired  size 
may  finally  be  secured  (Fig.  132).  To  prepare  a  chromic  acid  bead  on  the  end  of  the 


228  THE    PRINCIPLES   AND   PRACTICE    OF   OTOLOGY 

The  preparation  of  the  area  in  the  ear  which  is  to  be  touched  by 
the  caustic  is  no  less  important.  Caustics  have  a  tendency  to  spread 
rapidly  in  the  presence  of  moisture  and  to  damage 
the  surrounding  healthy  parts.  The  ear  should, 
therefore,  be  entirely  free  from  all  secretion  before 
the  application  of  any  caustic  is  undertaken. 

INJURIES  TO  THE  MEMBRANA  TYMPANI 
The  situation  of  the  tympanic  membrane  at  the 
bottom  of  the  deep  and  somewhat  angular  auditory 
meatus  is  one  that  affords  a  maximum  of  protection 
to  this  delicate  structure.  This,  together  with  its 
elasticity  of  structure  and  peculiar  setting  that  per- 
mits of  considerable  inward  and  outward  movement, 
accounts  for  the  comparatively  infrequent  injury  to 
this  portion  of  the  conducting  apparatus. 

Wounds  of  the  drum  membrane  are  either  direct 
or  indirect.     The  injury  to  the  membrane  may  con- 
stitute the  sole  damage  or  the  wound  may  be  of  such 
severity  that  not  only  is  the  structure  of  the  membrana 
FIG.  132.  — VERY     tympani    completely   destroyed,  but    also    the    parts 
fuclro"  mn*BxAo     beyond  it — namely,  the  ossicles,  the  mucous  lining  of 
OF  NITRATE  OF  SILVER     the  tympanum,  or  even  the  labyrinth  and  adjoining 

FUSED  ON  END.  *  J 

osseous  structures.  In  some  of  the  worst  injuries, 
that  to  the  drum  membrane  itself  constitutes  but  a  small  fraction  of 
the  damage  done  to  the  adjacent  parts. 

Direct  injuries  are  the  result  of  the  impact  or  penetration  of  the 
membrane  by  some  foreign  body  which  enters  the  external  auditory 
canal  with  sufficient  force  to  be  driven  deeply  into  the  fundus.  An 
individual  sometimes  wounds  his  own  drum  membrane  while  picking 
at  his  ear  or  while  scratching  the  canal  with  some  pointed  instrument, 
like  a  toothpick,  match,  or  hairpin.  Numerous  instances  arc  on  record 
of  injury  to  the  drum  membrane  occurring  from  some  one  accidentally 
striking  the  arm  of  a  person  who  is  at  the  time  engaged  in  picking  his 
ear  with  a  sharp  instrument,  which  latter  was  by  this  means  driven  in- 
ward with  force  and  suddenness. 

applicator,  place  a  few  fresh  crystals  of  the  acid  upon  a  piece  of  paper  and  hold  in  the 
left  hand  near  the  flame  of  the  alcohol  lamp.  Using  the  right  hand,  hold  the  tip  of  the 
applicator  in  the  flame  until  heated  almost  to  the  point  of  redness.  Very  quickly  bring 
the  heated  tip  of  the  applicator  into  contact  with  a  crystal  of  the  acid,  which  will  adhere 
and  fuse  upon  the  instrument  in  the  form  of  a  little  globule  of  most  convenient  size.  Con- 
siderable practice  will  be  necessary  to  prepare  the  chromic  acid  applicator  satisfactorily. 


DISEASES   AND    INJURIES   OF   THE    MEMBRANA   TYMPANI  2 29 

Any  foreign  body  that  is  hurled  with  sufficient  force  to  enter  the 
meatus  may  cause  a  direct  rupture  of  the  drum-head.  Children  at 
play  have  been  known  to  shoot  paper  wads,  grains  of  corn,  etc.,  into 
their  playmates'  ears  by  means  of  toy  air-guns.  The  membrana  tympani 
of  workmen  may  be  wounded  by  pieces  of  stone  or  other  material  which 
fly  off  from  the  particular  tools  employed,  as,  for  example,  in  the  case  of 
stone-cutters.  Another  and  rather  frequent  cause  of  direct  injury  to 
the  membrana  tympani  is  observed  in  the  case  of  surf-bathers  who 
permit  the  waves  to  strike  the  ear  side  wise  with  considerable  force.1 

Those  wrho  perform  high  diving  sometimes  suffer  an  injury  to  the 
drum  membrane  from  a  similar  cause,  since  the  water  enters  the  auditory 
canal  with  considerable  force  in  case  the  head  strikes  the  surface  of 
the  water  sidewise. 

It  sometimes  happens  that  rupture  of  the  drum  membrane  will 
take  place  during  treatment  of  the  ear,  even  though  this  be  conducted 
with  great  caution  and  skill.  Thus,  if  politzerization  or  catheter  inflation 
of  the  tympanic  cavity  be  performed,  and  too  much  air  pressure  be  used, 
direct  injury  to  the  membrana  tympani  may  be  the  result,  the  rupture 
taking  place  with  a  snap  sufficiently  loud  to  be  audible  a  distance  of 
several  feet.  It  is  probable  that  when  rupture  occurs  as  the  result  of 
tympanic  inflation  that  the  membrane  had  been  previously  diseased 
and  greatly  weakened,  and  that  it,  therefore,  gave  way  under  much 
less  air  pressure  than  would  be  required  to  rupture  the  normal  drum- 
head. Of  a  somewhat  similar  nature  is  the  rupture  which  occasionally 
results  from  the  too  vigorous  suction  upon  the  membrane  by  means 
of  the  Siegel  otoscope — an  accident  which  may  happen  when  this 
instrument  is  employed  for  the  purpose  of  giving  massage  to  the  mem- 
brana tympani  and  ossicles  (see  p.  174). 

Blows  upon  the  ear,  as  in  boxing,  and  falls  upon  the  head  from  a 
height  or  from  a  vehicle  in  rapid  motion  are  among  the  most  potent 
causes  of  severe  injury  to  the  drum  membrane  and  middle  ear  (Fig. 
133).  The  injury  thus  resulting  from  such  violent  causes  frequently 
extends  beyond  the  ear,  and  may  include  extensive  fractures  at  the  base 
or  other  portions  of  the  skull.  Fig.  305  represents  a  case  of  the  latter, 

1  It  is  quite  probable  that  a  considerable  number  of  deaths  by  drowning  which  occur 
during  surf-bathing  are  due  to  injuries  of  this  kind,  and  not  to  "cramps,"  as  is  commonly 
reported.  It  is  well  known  to  all  aurists  that  syringing  the  ears,  even  gently  and  with 
warm  solutions,  will  in  many  individuals  cause  great  giddiness  or  even  total  unconscious- 
ness for  a  few  seconds.  It  is  not  unreasonable,  therefore,  to  presume  that  the  entrance 
into  the  ear  of  cold  water  with  sufficient  force  to  rupture  the  drum  membrane  might 
cause  a  more  lasting  unconsciousness,  during  which  time  the  individual  succumbs  by 
drowning. 


230 


THE    PRINCIPLES    AND    PRACTICE    OF   OTOLOGY 


while  Figs.  133  and  134  show  the  effect  upon  the  drum  membrane  of 
severe  falls  upon  the  head,  without  a  fracture  of  the  skull  itself. 

Injuries  to  the  membrana  tympani  from  indirect  violence  occur 
principally  as  the  result  of  the  sudden  condensation  or  rarefaction  of 
the  air  in  the  external  auditory  meatus.  Thus,  any  loud  explosion,  as 
of  gun  or  cannon,  when  near  the  ear  may  bring  about  a  rupture  of  the 
tympanic  membrane.1  In  this  instance  the  air  is  driven  inward 
with  such  force  and  suddenness  that  the  resistance  of  this  structure  is 
overcome  and  it  gives  way  before  the  violence  of  the  increased  air- 
pressure.  Of  a  somewhat  similar  nature,  though  without  the  features 
of  sudden  compression  of  air  incident  to  an  explosion,  is  the  effect  of 


FIG.  134. — RUPTURE  or  DRUM-HEAD  AND 
FRACTURE  OF  HANDLE  OF  MALLEUS  RESULTING 
FROM  A  FALL  UPON  THE  HEAD  FROM  A  RAPIDLY 
MOVING  STREET-CAR. 

Child  aged  eight  years.  Profuse  hemorrhage 
immediately  followed  and  child  was  unconscious 
for  about  twelve  hours.  Complete  recovery  fol- 
lowed in  four  weeks. 


FIG.  133. — RUPTURE  or  THE  DRUM  MEMBRANE 
WITH  FRACTURE  OF  THE  XECK  OF  THE  MALLEUS  IN 
A  CHILD  AGED  NINE,  THE  RESULT  OF  FALLING 
DOWN  A  STAIRWAY. 

Profuse  hemorrhage  at  once  occurred  from 
the  external  auditory  meatus,  and  facial  paralysis 
developed  in  a  few  days  on  the  affected  side. 
There  was  also  disturbance  of  taste  on  the  same 
side,  showing  that  the  chorda  tympani  nerve  had 
been  injured.  Recovery  from  the  facial  palsy  was 
complete  in  a  few  month?,  showing  that  the  injury 
to  the  nerve  was  probably  due  to  an  exudate  or 
hemorrhage  into  the  Fallopian  canal. 


the   air  within   a   caisson   upon  the  membrana   tympani,  occasionally 
causing  its  rupture. 

It  is  a  question  of  practical  interest  as  to  whether  or  not  a  severe 
injury  or  rupture  of  the  normal  drum-head  can  occur  from  such  indirect 
causes  as  a  loud  explosion,  or  from  an  existence  for  a  short  time  in  a 
condensed  atmosphere,  as  in  a  caisson  or  diver's  bell.  As  a  result 
of  the  examination  of  a  considerable  number  of  accidents  to  the  mem- 
brana tympani  from  these  causes,  several  authors  have  stated  it  as 
their  opinion  that  the  rupture  under  such  circumstances  was  due  to 
the  fact  of  a  pre-existing  disease  of  the  ear,  usually  in  the  nature  of  a 

1  During  the  war  with  Spain,,  between  the  months  of  April  and  August,  1898,  10 
cases  of  rupture  of  the  membrana  tympani,  as  the  result  of  the  firing  of  cannon,  were 
reported  among  the  crews  of  the  North  Atlantic  Squadron,  and  19  cases  of  this  variety 
of  injury  to  the  membrana  tympani  occurred  among  the  men  of  the  Japanese  crews  in 
the  battle  of  the  Yalu  during  the  recent  Russo-Japanese  war. 


DISEASES    AND    INJURIES    OF   THE    MEMBRANA   TYMPANI  231 

catarrhal  inflammation  of  the  middle  ear  accompanied  by  more  or 
less  occlusion  of  the  Eustachian  tube,  and  .consequent  rarefaction  of  the 
air  within  the  tympanum.  Gruber  (Lehrbuch  der  Ohrenheilkunde, 
p.  310)  has  experimentally  shown  that  it  is  difficult  to  rupture  the 
healthy  drum  membrane  in  the  cadaver.  This  author  inserted  the 
catheter  into  the  Eustachian  tube  of  a  person  recently  dead,  fastened 
it  in  position,  and  then  suddenly  injected  4  or  5  atmospheres — a  pressure 
of  from  60  to  75  pounds — into  the  middle  ear  and  against  the  normal 
membrane.  He  then  reversed  the  experiment  and  injected  equally 
high  pressure  against  the  drum  membrane  through  the  external  audi- 
tory canal.  Such  a  high  pressure  thrown  suddenly  against  the  healthy 
drum  membrane  on  either  side  wras  not  sufficient  to  rupture  it. 

When  injury  occurs  to  the  membrana  tympani  as  the  result  of  the 
penetration  of  some  slender  instrument,  the  particular  quadrant  which 
is  perforated  (see  Fig.  187)  depends  in  some  measure  upon  the  degree 
of  suddenness  and  force  with  which  the  entrance  is  effected,  and  upon 
whether  or  not  the  entering  end  of  the  object  is  sharp  or  blunt.  It 
will  be  remembered  that  the  drum  membrane  is  normally  placed  at 
such  an  angle  to  the  external  auditory  meatus  that  the  posterosuperior 
quadrant  lies  nearer  to  the  concha  than  does  the  anterosuperior  quad- 
rant. 

If,  therefore,  the  object  is  sharp  pointed  and  is  quickly  thrust  into 
the  depths  of  the  canal  the  posterosuperior  portion  will  most  likely  be 
perforated,  whereas,  if  the  object  be  blunt  pointed  and  is  entered  with 
comparative  slowness,  it  may  slip  over  the  posterior  portion  of  the 
slanting  surface  of  the  membrana  tympani  and  penetrate  one  of  the 
anterior  quadrants.  Zaufal  (Archives  fur  Ohrenheil.,  Vol.  VIII.),  in 
experiments  on  the  cadaver,  states  that  direct  rupture  of  the  drum  mem- 
brane most  usually  occurs  in  the  anterior  half  of  the  tympanic  mem- 
brane, whereas  Politzer  (Diseases  of  the  Ear,  p.  242)  and  Dench  (Dis- 
eases of  the  Ear,  p.  292)  state  that  when  caused  by  the  penetration  of 
instruments  the  injury  occurs  in  the  posterosuperior  quadrant. 

Symptoms. — At  the  moment  of  the  rupture  of  the  membrane  the 
individual  experiences  a  sharp,  lancinating  pain  in  the  ear  which,  while 
subsiding  to  some  extent  in  a  short  time,  continues  as  a  feeling  of  more 
or  less  deep-seated  pain  and  soreness.  Giddiness  occurs  at  the  in- 
stant of  the  injury,  and  is  often  of  such  severity  that  complete  uncon- 
sciousness takes  place  for  a  short  time.  Sometimes  the  dizziness 
persists  for  weeks  or  months  and  is  accompanied  by  a  tinnitus  of  varying 
degrees  of  intensity.  The  degree  of  impairment  of  hearing  that  results 
from  the  injury  depends  upon  the  severity  and  nature  of  the  wound 


232  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

and  upon  whether  or  not  a  suppurative  inflammation  is  subsequently 
set  up.  Immediately  following  a  severe  wound  of  the  drum  membrane 
there  is  usually  profuse  bleeding  from  the  external  auditory  mcatus, 
and  this  is  shortly  followed  in  some  cases  by  a  discharge  of  serum, 
which  after  a  few  days  becomes  infected  and  assumes  a  purulent  charac- 
ter. Should  a  fracture  of  the  base  of  the  skull  complicate  the  aural 
injury,  the  subsequent  discharge  of  bloody  serum  may  be  one  of  the 
notable  symptoms  of  that  occurrence.  After  suppuration  is  once 
established  the  subsequent  symptoms  of  the  case  may  differ  in  no 
important  particular  from  those  occurring  in  acute  or  chronic  suppura- 
tive otitis  media. 

Otoscopic  appearances  of  the  drum  membrane  after  a  rupture  or 
other  injury  vary  according  to  the  extent  and  cause  of  the  injury,  and 
also  as  to  the  time  which  has  elapsed  between  the  injury  and  the  ex- 
amination of  the  case.  If  the  membrane  has  been  penetrated  by  some 
slender,  sharp  instrument,  and  the  wound  is  examined  immediately 
afterward,  a  puncture-point  will  most  likely  be  seen  in  the  postero- 
superior  quadrant,  the  site  being  marked  by  a  small  drop  of  blood. 
When  of  a  severe  nature,  the  bleeding  from  the  meatus  may  be  so  pro- 
fuse as  to  preclude  an  exact  inspection  of  the  drum  membrane  for 
several  days,  as  was  the  case  in  each  of  the  patients  from  which  the 
drawings  for  Figs.  133  and  134  were  made.  In  Fig.  133  the  bleeding 
was  so  severe  that  it  was  necessary  to  tampon  the  meatus  with  sterile 
gauze  for  several  days,  after  which  the  oozing  of  bloody  serum  inter- 
fered with  accurately  determining  the  extent  of  the  wound  until  twelve 
days  from  the  date  of  the  accident.  At  this 
time  the  appearance  was  as  shown  in  the  figure. 
When  due  to  indirect  causes  the  injury  to  the 
drum  membrane  occurs  most  frequently  in  the 
postero-inferior  quadrant,  and  the  rent,  when 
viewed  through  the  speculum,  appears  as  a  gaping 
slit  (Fig.  135)  through  which  the  mucous  membrane 
FIG.  135.— SLIT-LIKE  RUP-  of  the  middle  ear  can  sometimes  be  seen,  provided 

TURK   OF    DRUM-HEAD    RE-  . 

SULTING  FROM  A  BOX  UPON  the  examination  be  made  early.  Later,  if  the 
wound  be  not  large  and  the  gaping  therefore 
not  extensive,  nothing  more  is  visible  than  a  linear,  blackish  blood- 
clot,  which  has  sealed  the  wound  and  furnished  a  most  efficient 
natural  dressing. 

In  all  injuries  to  the  ear,  and  especially  to  the  membrana  tympani 
and  middle  ear,  it  is  important  that  the  examining  surgeon  make  a 
complete  record  at  the  time  of  the  first  examination  of  the  results  of 


DISEASES    AND   INJURIES   OF   THE   MEMBRANA   TYMPANI  233 

the  hearing  tests,  the  history  of  the  accident,  and  the  exact  appearance 
of  the  tympanic  membrane  when  viewed  through  the  speculum.  Such 
a  record  is  particularly  important  in  all  cases  where  there  is  a  probability 
of  subsequent  suit  for  damages,  at  which  time  the  attending  surgeon 
will  certainly  be  called  to  testify  concerning  the  extent  and  probable 
permanency  of  any  alleged  defect  resulting  from  the  injury.  When 
fortified  by  the  record  of  a  most  careful  and  accurate  examination  of  an 
injured  ear,  made  at  the  time  of  the  injury,  the  testimony  of  the  surgeon 
becomes  competent  and  most  reliable  evidence,  upon  which  the  court 
and  jury  must  largely  rely. 

Treatment. — Many  of  the  lesser  injuries  to  the  membrana  tympani 
require  little  or  no  treatment.  If  seen  early  and  the  wound  is  found  to  be 
trivial,  and  especially  if  it  is  already  sealed  by  a  blood-clot,  the  best  results 
are  secured  by  non-interference  with  the  injured  part,  since  nothing 
more  is  required  than  the  insertion  of  a  sterile  strip  of  gauze  or  a  pledget 
of  antiseptic  cotton  into  the  external  auditory  canal.  When  the  wound 
is  large  and  has  been  produced  by  direct  violence,  infection  of  the 
middle  ear  from  the  external  auditory  meatus  is  almost  certain  to  follow. 
Hence  it  is  wise  to  attempt  the  sterilization  of  the  external  auditory 
canal  in  the  hope  that  a  middle-ear  infection  may  be  avoided.  Disin- 
fection of  the  auditory  canal  is  best  and  most  safely  accomplished  by 
rubbing  both  the  hairy  and  deeper  integumentary  surfaces  with  a 
cotton-tipped  probe  that  has  been  dipped  into  either  hydrogen 
peroxid  or  alcohol  and  boric  acid  solution.  Under  no  circumstances 
should  the  external  auditory  meatus  be  syringed  previously  to  the  time 
when  suppuration  is  already  established  as  the  result  of  the  injury, 
for  if  syringing  is  practised  previously  to  this  time,  infective  material 
will  almost  certainly  be  carried  from  the  meatus  into  the  middle  ear, 
where  it  will  cause  destruction  of  parts  that  might  otherwise  heal 
without  undergoing  the  suppurative  stage  of  inflammation.  If  the 
edges  of  the  wound  in  the  membrane  are  moist,  it  is  permissible,  after 
the  application  of  the  antiseptic  to  the  meatal  walls  as  just  described, 
to  insufflate  a  small  quantity  of  some  mild  antiseptic  or  drying  powder, 
like  boric  acid,  in  sufficient  amount  to  form  a  delicate  coating  over 
the  drum  membrane  and  adjoining  meatal  walls.  Following  this,  if 
any  moisture  is  visible,  superheated  dry  air  may  be  injected  into  the 
meatus,  after  which  the  dressing  is  completed  by  the  insertion  of  a  strip 
of  sterile  gauze  to  the  bottom  of  the  auditory  meatus,  the  gauze  being 
left  in  place  till  healing  occurs,  unless  infection  has  taken  place  and  the 
dressing  becomes  soiled  and  foul  smelling. 

In  case  severe  pain  arises  in  the  ear  the  same  may  be  due  to  the  col- 


234  THE    PRINCIPLES    AND   PRACTICE    OF   OTOLOGY 

lection  of  serum  or  blood  in  the  tympanic  cavity.  This  would,  of  course, 
happen  only  in  cases  where  the  perforation  is  small.  An  examination 
with  the  speculum  would  reveal  a  bulging  and  inflamed  drum  mem- 
brane which  should  be  freely  incised  in  order  to  provide  the  necessary 
drainage.  In  all  cases  in  which  suppuration  is  ultimately  established 
as  a  result  of  the  injury  the  subsequent  treatment  should  be  conducted 
upon  the  same  plan  which  is  advocated  in  the  chapter  on  Acute  Suppu- 
rative  Otitis  Media,  from  which  the  disease  in  question  differs  in  no 
essential  respect  (see  Chapter  XXIII.). 


CHAPTER  XXI 
ACUTE  TUBOTYMPANIC  CATARRH 

Causation. — Catarrhal  affections  of  the  Eustachian  tube  and 
middle  ear  are  of  frequent  occurrence,  particularly  during  the  cold 
and  changeable  seasons  of  the  year  and  in  damp  climates.  All  the 
causes  that  are  productive  of  colds  in  the  head  may  be  considered  causa- 
tive agents  of  Eustachian  and  tympanic  catarrh.  This  affection  is, 
therefore,  very  frequently  observed  to  accompany  or  complicate  a  coryza 
or  nasopharyngitis.  The  milder  types  of  the  exanthemata  produce 
conditions  in  the  throat  that  are  causative  of  catarrhal  affections  of  the 
tube  and  middle  ear,  whereas  the  more  severe  cases  of  scarlet  fever  or 
measles  are  more  likely  to  be  complicated  by  an  actual  inflammation 
and  suppuration  of  the  tympanic  cavity.  The  accidental  injection  of 
fluids  into  the  Eustachian  orifice  during  the  treatment  of  a  nasopharyn- 
gitis may  also  be  responsible  for  the  disease  under  consideration,  although 
such  an  accident  is  most  often  followed  by  the  more  severe  affection, 
namely,  an  acute  otitis  media,  either  of  the  catarrhal  or  purulent  variety. 

The  most  common  of  the  predisposing  causes  of  this  disease  is  the 
presence  in  the  nasopharynx  of  adenoid  growths,  and  it  is  entirely 
probable  that  it  is  in  this  particular  ailment  that  adenoids  prove  most 
harmful  to  the  individual.  This  is  especially  true  since,  occurring  as 
they  so  frequently  do  in  children,  the  causative  relation  between  the 
adenoid  and  the  accompanying  deafness  is  not  suspected  early,  or  if 
at  all  suspected  is  not  dealt  with  until  structural  changes  within  the  ear 
of  an  incurable  nature  have  already  been  established.  A  complete 
understanding  by  the  student  of  the  anatomy  and  physiology  of  the 
Eustachian  tube  and  middle  ear  will  make  clear  the  necessity  of  having 
the  nasopharynx  free  from  all  obstruction  or  inflammation.  The 
presence  of  adenoids  predisposes  the  individual  to  frequent  or  even 
continuous  colds  in  the  head,  and  to  the  production  of  congestion  and 
oversecretion  of  mucus  which  blocks  the  Eustachian  tubal  orifices,  and 
thus  prevents  the  necessary  entrance  of  air  into  the  middle  ear.  More- 
over, with  the  nasopharynx  occluded  by  these  growths,  covered  as  they 
are  by  ropy  mucus,  a  suction  and  rarefaction  of  the  air  in  this  space 
is  produced  by  each  act  of  swallowing.  Then,  too,  the  growth  of 
numerous  pathogenic  bacteria  in  the  nasopharynx  is  favored  by  the 

235 


236  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

presence  of  the  adenoids,  and  hence  infection  may  arise  in  the  middle 
ear  as  the  result  of  the  oft-repeated  and  forcible  efforts  of  the  individual 
to  clear  the  obstructed  nasal  passages,  during  which  efforts  bacteria- 
laden  mucus  may  be  blown  through  the  Eustachian  tube  into  the 
middle  ear. 

Pathology. — In  acute  tubotympanic  catarrh  the  inflammation 
may  be  limited  to  the  Eustachian  tube  alone  or  it  may  spread  to  the 
middle  ear.  A  catarrhal  inflammation  takes  place  with  formation  of 
serous  or  mucous  secretion.  The  obstruction  of  the  Eustachian  tube 
when  the  inflammation  is  limited  to  the  tube  is  generally  followed  by 
a  serous  transudation  in  the  tympanic  cavity  due  to  rarefaction  of  the 
tympanic  air.  This  rarefaction  of  the  air  is  brought  about  by  absorption 
of  the  air  by  the  lining  mucous  membrane  of  the  middle  ear.  Whether 
the  inflammatory  or  mechanical  obstruction  is  at  the  mouth  of  the 
Eustachian  tube,  a  limited  portion,  or  along  the  whole  tube,  the  function 
of  the  tube  (the  wind-pipe  of  the  middle  ear)  is  destroyed  and  this 
results  in  a  lessened  air  pressure  in  the  middle  ear.  The  equilibrium 
or  balance  of  the  drum  membrane  is  destroyed  because  the  outward 
atmospheric  pressure  is  greater  than  the  inner  atmospheric  pressure 
and  the  drum  and  malleus  are  pushed  inward.  This  causes  the  short 
process  to  appear  more  prominent  and  causes  the  malleus  to  appear 
foreshortened.  The  head  of  the  malleus  is  pushed  toward  the  external 
attic  wall.  Meanwhile  the  whole  middle-ear  cavity  becomes  hyperemic 
and  if  the  obstruction  in  the  tube  is  not  removed  a  transudate  is  formed. 
Also,  as  often  happens  in  children  with  adenoid  growth,  the  drum  mem- 
brane becomes  atrophied.  This  atrophy  is  brought  about  by  the 
continual  tension  of  the  drum  membrane  which  causes  a  lessened  blood 
supply  to  the  mucous  membrane  lining. 

Symptoms. — The  symptoms  vary  during  the  different  stages  of  the 
disease.  Thus,  at  the  onset,  when  the  affection  consists  of  nothing 
more  than  a  closure  of  the  cartilaginous  portion  of  the  Eustachian 
tube,  followed  by  the  absorption  into  the  blood  of  the  air  remaining 
in  the  middle  ear,  the  membrana  tympani  is  no  longer  supported  by  air 
pressure  on  its  tympanic  surface,  and  therefore  the  normal  air  column 
on  the  outside  of  the  drum-head  presses  it  inward  with  a  force  approxi- 
mating 15  pounds  to  the  square  inch.  The  resulting  symptoms  are, 
therefore,  largely  of  a  physical  nature.  The  hearing,  which  had  been 
previously  good,  is  suddenly  very  greatly  diminished,  and  a  tinnitus 
aurium  of  greater  or  less  intensity  is  established.  In  cases  where  the 
onset  is  sudden  and  of  marked  severity  vertigo  may  be  a  prominent 
symptom. 


ACUTE  TUBOTYMPANIC  CATARRH  237 

Since  no  active  inflammation  is  present  except  perhaps  in  a  portion 
of  the  Eustachian  tube,  but  slight  or  even  no  pain  is  present.  The 
patient  complains  rather  of  a  soreness,  which,  if  he  is  requested  to  locate, 
he  will  attempt  to  do  so  by  pointing  to  almost  every  quarter  of  his  neck 
and  throat.  A  decided  stuffiness  in  the  ears  is  the  chief  complaint  of 
many,  who  say  that  there  is  a  feeling  in  the  ears  as  though  a  foreign 
body  occluded  both  external  auditory  meati,  and  hence  persons  so 
affected  have  an  irresistible  desire  to  be  poking  into  the  auditory  canals 
with  their  fingers  in  their  efforts  to  relieve  this  very  uncomfortable  feel- 
ing. Sometimes  the  suction  produced  by  the  sudden  withdrawal  of 
the  finger  from  the  external  auditory  canal  will  to  some  extent  replace 
the  sunken  drum  membrane  and  give  the  patient  a  very  temporary 
relief— a  result  which  will  encourage  him  to  repeat  the  procedure. 
The  appearance  of  the  drum  membrane  when  viewed  by  means  of  an 
ear  speculum  and  reflected  light  is  usually  one  of  great  retraction  (Fig. 
136).  The  folds  of  the  membrane  are  more  distinct,  the  short  process 
is  more  prominent,  and,  because  the  membrane  is  more  tightly  stretched 
over  it,  this  process  of  the  malleus  looks  whiter  than  normal.  Since  the 
handle  of  the  malleus  is  driven  inward,  and  hence  away  from  the 
examiner,  it  appears  more  distant  and  much  shorter  than  normal.  The 
new  position  of  the  manubrium  divides  the  mem- 
brana  tympani  into  unequal  parts,  the  antero- 
inferior  portion  appearing  unusually  broad  .while 
the  posterosuperior  seems  greatly  narrowed  (Fig. 

136). 

Both  the  color  and  lustre  of  the  membrane 
remain  normal,  but  the  light  reflex  is  usually 
removed  somewhat  from  its  normal  position;  it  is  FIG.  136.— RETRACTION  OF 

,-  i        i  i,.    i  i  i          i,          ,1  DRUM  MEMBRANE. 

at  times  broken  or  multiple  and  may  be  altogether        Note  the length  of  ^^ 
absent.     The    close  proximity  of  the  membrana     reflex.  &e  shortening  of  the 

.  .  malleus     handle,     and     the 

tympani  to  the  inner  wall  of  the  tympanic  cavity  widened  area  of  the  antero- 
occasionally  permits  the  penetration  of  the  re-  *****  <»uadrant- 
fleeted  light  through  the  membrane  to  such  an  extent  that  the  color 
of  the  mucous  membrane  of  the  tympanic  cavity  is  imparted  to  the 
tympanic  membrane,  in  which  case  the  color  of  the  latter  will  be 
deceptive  and  may  appear  reddened  or  pinkish. 

The  appearance  of  the  drum  membrane  after  inflation  of  the  tym- 
panic cavity  by  means  of  the  catheter  or  by  politzerization  is  completely 
changed,  the  normal  position  of  all  the  parts  being  at  once  restored  unless, 
as  sometimes  happens,  an  exudate  has  already  taken  place  into  the 
tympanic  cavity. 


238  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

In  the  second  stage  of  the  disease,  after  the  congestion  has  extended 
to  the  mucous  lining  of  the  middle  ear,  and  exudation  has  taken  place, 
all  the  symptoms  previously  enumerated,  the  impaired  hearing,  tinnitus, 
and  stuffy  feeling  in  the  ear,  continue,  but  in  a  somewhat  lessened 
degree.  In  the  more  active  forms  of  the  tubotympanic  congestion  the 
attic  of  the  middle  ear  may  be  involved,  in  which  case  pain  in  the  ear  of 
a  varying  degree  of  severity  may  be  added.  After  the  exudate  has  taken 
place  and  has  partly  filled  the  tympanic  cavity,  the  patient  may  state 
that  during  the  time  the  head  is  held  in  certain  positions  he  hears  badly, 
whereas,  in  other  positions  the  hearing  is  relatively  good.  Thus,  when 
sitting  upright  only  slight  impairment  of  function  may  be  experienced, 
whereas,  the  moment  the  patient  lies  upon  the  back  or  holds  the  head 
toward  the  opposite  side,  great  impairment  immediately  takes  place. 
These  marked  changes  occur  chiefly  in  cases  where  the  tympanic  cavity, 
as  above  stated,  is  only  partially  filled  with  serous  fluid,  and  hence  the 
change  in  hearing  results  from  the  changed  position  of  the  fluid.  Thus, 
when  the  patient  is  erect  the  round  and  oval  windows  are  not  covered 
by  the  contained  fluid  and  the  hearing  is  comparatively  good,  whereas, 
in  the  recumbent  position,  the  exudate  occupies  these  situations  and 
the  hearing  is  relatively  bad.  It  is  because  of  the  movement  of  the  fluid 
within  the  tympanum  that  the  patient  may  also  state  that  he  sometimes 
feels  as  though  a  liquid  were  moving  in  the  ear  whenever  the  position 
of  the  head  is  changed.  As  patients  sometimes  express  it,  they  "feel 
something  slushing  about  in  the  head." 

Autophonia,  or  a  resonance  of  the  patient's  own  voice  in  the  affected 
ear,  is  a  symptom  in  many  cases,  and  when  present  in  its  worst  form 
constitutes  one  of  the  most  annoying  features  of  the  disease.  The 
patient  describes  the  sound  of  his  voice  as  resembling  that  heard  "  when 
talking  in  a  barrel."  This  sensation  is  so  distressing  to  many  individuals 
that  they  prefer  to  sit  silent  throughout  the  illness  and  are  greatly  an- 
noyed when  compelled  to  enter  into  even  a  short  conversation.  Gruber 
states  that  autophonia  is  most  frequently  an  annoying  symptom  in  mild 
cases  of  tubotympanic  congestion,  and  in  those  cases  in  which  there 
is  present  only  a  small  amount  of  exudate  in  the  middle  ear.  This 
symptom  is  also  worse  in  those  who  are  affected  by  the  disease  in  one 
ear  only.  In  most  individuals  who  are  afflicted  with  several  of  the 
accompanying  symptoms  of  this  form  of  aural  catarrh,  namely,  impaired 
hearing,  tinnitus  aurium,  vertigo,  pressure  in  the  head  and  autophonia, 
there  quickly  develops  an  unwarranted  apprehension  of  permanent 
injury  to  the  function,  and  of  a  subsequent  life  spent  in  social  isolation. 
Children  who  suffer  from  this  disease  and  who  have  in  addition  large 


ACUTE  TUBOTYMPANIC  CATARRH 


239 


nasopharyngeal  adenoids,  acquire  a  characteristic  and  expressionless 
countenance,  which,  together  with  the  open  mouth  and  lack  of  attention 
because  of  the  poor  hearing,  constitutes  that  condition  which  Guye,  of 
Amsterdam,  has  called  aprosexia  (see  Fig.  117). 

The  appearance  of  the  drum  membrane  during  the  second  stage 
and  after  an  exudate  has  taken  place  into  the  cavity  of  the  middle  ear 
varies  somewhat  according  to  the  amount,  character,  and  color  of  the 
exudate,  the  degree  of  transparency  of  the  tympanic  membrane,  and 
finally,  the  amount  of  congestion  within  the  middle  ear,  and  the  conse- 
quent color  of  the  mucous  lining  which  may  be  seen  through  the  trans- 
lucent membrane  by  reflected  light.  In  the  first  place,  the  degree  of 
retraction  of  the  drum  membrane  is  not  usually  so  great  as  in  the  first 
stage,  but  the  short  process  and  handle  of  the  malleus  continue  to  stand 
out  prominently.  A  comparison  of  the  color  of  the  upper  with  the 


FIG.  137. — EXUDATE  IN  THE  INFERIOR  PORTION  OF 

TYMPANIC  CAVITY. 

Note  slightly  crescentic  line  marking  level  of  fluid. 
Viewed  through  speculum,  patient's  head  erect. 


FIG.  138. — SHOWING  THE  CHANGED  RELATIONS 
OF  THE  EXUDATE  WHEN  THE  HEAD  OF  THE  PATIENT 
is  TILTED  FORWARD  TOWARD  THE  HORIZONTAL 
PLANE. 

Same  ear  as  shown  in  Fig.  137. 


lower  quadrant  of  the  drum  membrane  will  often  show  a  decided  differ- 
ence in  this  stage,  for  whereas  the  upper  portion  of  the  membrane 
may  retain  its  normal  pearly-gray  or  slightly  pinkish  appearance,  the 
lowermost  portion  looks  slightly  yellowish  or  straw  colored,  for  the 
reason  that  the  yellowish  exudate  within  the  tympanic  cavity  shows 
through  the  translucent  membrana  tympani.  The  level  of  this  liquid 
in  the  drum  cavity  is  indicated  on  the  drum  membrane  by  a  distinct 
line,  the  color  of  which  may  be  dark  gray,  white,  or  black.  The  direction 
of  this  line  is,  in  the  main,  horizontal  from  before  backward,  but  may 
be  slightly  crescentic  (Fig.  137),  concavoconvex,  or  inverted  V  shaped. 
If  the  contained  fluid  is  thin  and  serous,  and  the  patient's  head  be 
moved  into  different  positions  (Fig.  238)  during  the  examination,  the 
line  may  be  seen  to  change  its  relation  to  the  tympanic  structures  at 
each  change  in  the  position  of  the  patient  (Fig.  138).  Should  the 
exudate  consist  of  a  thick,  ropy  mucus,  the  above-mentioned  changes 


240  THE    PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 

may  not  occur  at  all,  or  if  they  take  place  they  do  so  very  slowly  because 
of  the  greater  density  of  the  exudate.  When  the  exudatc  is  sufficient 
in  quantity  to  fill  the  tympanic  cavity,  no  line  will,  of  course,  mark  its 
level  and  hence  one  cannot  be  seen.  In  this  case  the  whole  or  at  least 
some  portion  of  the  drum  membrane  will  be  found  bulging  to  some 
degree,  and  a  slightly  yellowish  and  characteristic  color  will  be  observed 
over  a  greater  or  less  area  of  the  drum  membrane  unless  the  latter  is 
from  some  cause  opaque. 

If  during  the  examination  of  a  drum  membrane,  beyond  which 
there  is  a  collection  of  exudate  in  the  tympanic  cavity,  the  tympanum 
should  be  inflated  by  means  of  the  catheter  or  by  the  Politzer  method, 
bubbles  of  air  will  be  seen  to  arise  from  the 
antero- inferior  quadrant  near  the  tympanic  ring — 
the  tympanic  orifice  of  the  Eustachian  tube — and 
finally  to  become  lost  above  the  surface-line  of 
the  fluid.  In  case  this  fluid  is  of  a  syrupy  con- 
sistency the  air-bubbles  will  be  entangled  in  it, 
will  rise  very  slowly,  therefore,  or  they  may  stand 
quiescent  in  the  fluid  for  a  considerable  length  of 

FIG.  139. — SHOWING  AIR 

BUBBLES  IN  THE  EXUDATE     time.      During    this   experiment   the   catheter   is 

AFTER  CATHETER  INFLATION       •  ,    j    •    ,       , i  i  i  . i        r   -i       -p1 

OF  THE  TYMPANIC  CAVITY.  inserted  into  the  pharyngeal  mouth  of  the  Eusta- 
chian tube  in  the  usual  way,  after  which  the  in- 
strument is  held  in  place,  and  the  inflation  is  performed  by  an  assis- 
tant, while  the  examiner  watches  the  effect  of  the  entrance  of  air  into 
the  tympanic  cavity,  upon  both  the  contained  fluid  and  the  membrana 
tympani  (Fig.  139). 

Mouth-breathing,  due  to  an  obstructed  nose  or  nasopharynx,  is  a 
symptom  which  is  observed  in  the  majority  of  all  cases  of  tubotympanitis 
occurring  in  children  and  young  adults.  An  examination  of  the  naso- 
pharynx will  usually  reveal  the  presence  of  adenoids.  In  older  persons 
the  postrhinoscopic  mirror  will  usually  enable  the  examiner  to  make 
out  a  chronic  nasopharyngitis,  which  may  be  seen  to  involve  the  lips 
of  the  Eustachian  tube,  the  entrance  to  which  is  often  blocked  by  tena- 
cious mucus.  Frequent  head  colds  accompanied  by  nasal  stoppage, 
blowing  of  the  nose,  and  hawking  and  spitting  are  symptoms  almost 
constantly  present. 

Diagnosis. — The  diagnosis  is  made  from  the  symptoms  narrated 
by  the  patient,  from  the  presence  of  an  exudate  in  the  tympanic  cavity, 
and  from  the  abnormal  position  of  the  membrana  tympani.  A  physical 
examination  of  the  fundus  of  the  ear  and  also  of  the  nose  and  naso- 
pharynx is  in  every  case  essential  to  a  correct  diagnosis.  Acute  closure 


ACUTE  TUBOTYMPANIC  CATARRH  24! 

of  the  Eustachian  tube  may  be  strongly  suspected  from  the  symptoms 
alone,  but  the  malposition  of  the  membrane  and  the  subsequent  presence 
of  an  exudate  within  the  tympanic  cavity  must  each  be  actually  seen 
before  it  can  be  said  with  certainty  that  a  tubotympanic  catarrh  is 
present.  The  line  marking  the  surface  of  the  effusion  into  the  drum 
cavity  (see  Fig.  139)  is  not  often  as  well  marked  as  the  figures  here  given 
would  indicate,  and  in  many  instances  such  a  line  is  with  difficulty 
distinguished  by  the  examiner.  The  color  of  the  exudate  is  usually 
of  a  light  straw,  or  even  deeper  yellow  color,  and  is  therefore  in  strong 
contrast  to  the  normal  color  of  that  portion  of  the  membrane  above 
the  level  of  the  fluid.  A  difference  in  the  color  of  the  upper  and  lower 
portions  may  not  be  noted  by  the  examiner,  for  the  reason  that  the  whole 
tympanic  membrane  may  be  so  thickened  or  congested  as  to  entirely 
obscure  the  parts  beyond.  When  this  is  the  case  the  diagnosis  as  to 
the  presence  of  fluid  can  be  made  from  the  character  of  the  auscultatory 
sounds,  which  may  be  heard  during  catheter  inflation,  should  the  exam- 
iner connect  the  ear  of  the  patient  with  his  own,  by  means  of  the 
auscultatory  tube  (Fig.  113).  The  sounds  heard,  if  fluid  be  present  in 
the  drum  cavity,  are  bubbling  or  snapping,  according  to  whether  the 
fluid  in  the  ear  through  which  the  air  passes  is  thin  or  is  mucoid  and 
syrupy.  If  the  fluid  completely  fills  the  drum  cavity;  if  the  drum  mem- 
brane is  opaque  and  the  fluid  cannot  for  this  reason  be  seen;  if  the  drum 
membrane  is  bulging  at  some  point,  for  these  reasons  an  incision  of  the 
membrana  is  justifiable  for  diagnostic  purposes,  and  the  outflow  of 
serum  or  thick  mucus  which  follows  furnishes  definite  information 
concerning  the  nature  of  the  tympanic  affection. 

Prognosis. — The  prognosis  depends  much  upon  the  early  recogni- 
tion of  the  exact  nature  of  the  aural  affection  and  upon  the  promptness 
with  which  proper  treatment  is  instituted  for  its  relief.  It  is  in  this 
particular  disease  that  procrastination  as  to  treatment,  especially  in  the 
case  of  children,  is  not  only  tolerated,  but  is  also  often  desired  on  the 
part  of  those  who  have  the  care  of  these  little  unfortunates.  The  old 
and  widely  quoted  advice,  "to  let  the  child  alone  and  it  \vill  outgrow  its 
aural  ailment,"  has  wrought  incalculable  mischief  in  this  class  of  aural 
diseases,  because  when  allowed  to  go  untreated  the  child  usually  grows 
into  and  not  out  of  the  disease ;  and  what  is  most  unfortunate  concerning 
this  subsequent  unfavorable  progress  of  the  aural  affection  is,  that  if 
left  to  itself,  by  the  time  the  child  has  reached  an  age  to  think  and  act 
for  himself  in  the  matter,  the  aural  disease  has  often  reached  a  stage 
that  is  absolutely  incurable. 

When  the  patient  is  in  good  health  otherwise  and  his  environment 

16 


242  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

is  in  no  way  faulty,  a  rapid  return  to  the  normal  condition  of  the  ear 
may  be  anticipated  as  a  result  of  early  treatment.  In  cachectic  individ- 
uals, who  must  continue  to  live  under  unhygienic  circumstances,  and 
who  are  exposed  a  great  deal  to  dampness  and  cold,  the  prognosis  is 
not  so  good.  In  neglected  cases  the  exudate,  with  its  accompanying 
symptoms  of  deafness,  tinnitus,  etc.,  may  continue  for  months  and 
years,  the  retained  secretion  may  finally  organize,  and  bands  of  connec- 
tive tissue  may  form  as  a  result,  these  latter  causing  ankylosis  of  the 
ossicles  and  permanent  immobility  of  the  membrana  tympani. 

Treatment. — In  the  first  stage,  while  the  affection  consists  merely 
of  a  closure  of  the  Eustachian  tube  together  with  the  consequent  dis- 
placement of  the  drum  membrane  inwardly,  the  treatment  consists  in 
restoring  the  patency  of  the  tube  to  the  normal  and  of  removing  the 
local  predisposing  cause  of  the  disease. 

The  Eustachian  tube  may  be  opened  and  the  tympanic  cavity  in- 
flated by  means  of  the  Eustachian  catheter  or  by  the  Politzer  method. 
It  may  in  a  general  way  be  said  that  the  catheter  should  be  employed 
in  a  majority  of  all  adult  cases  in  whom  the  nose  or  nasopharynx  is  not 
greatly  inflamed  or  exquisitely  tender,  whereas  inflation  by  the  Politzer 
bag  is  particularly  suited  for  use  in  young  children  and  in  adults  where 
the  nose  and  nasopharynx  are  acutely  inflamed  and  oversensitive  to 
the  use  of  instruments.  Inflation,  when  successfully  performed  by 
either  method,  will  immediately  improve  the  hearing  to  a  very  marked 
degree,  provided  it  was  normal  previously  to  the  time  of  the  present 
affection.  When  much  swelling  of  the  mucous  lining  of  the  Eustachian 
tube  is  present  as  a  result  of  the  extension  of  the  neighboring  nasopharyn- 
gitis,  it  is  sometimes  difficult  to  inflate  the  tympanic  cavity  by  any 
method.  In  such  instances  the  catheter  is  preferable,  but  before  at- 
tempting its  introduction  the  nose  and  nasopharynx  should  be  prepared 
by  thoroughly  spraying  the  same  with  normal  salt  solution,  and  after- 
ward applying  a  4  per  cent,  solution  of  cocain  to  the  inferior  meatus, 
to  the  lateral  wall  of  the  nasopharynx,  and  to  the  mouth  of  the  Eustachian 
tube.  The  nasopharynx  and  nasal  chambers  are  often  found  covered 
with  tenacious  mucus,  and  the  nasopharyngeal  mouth  of  the  tube  is 
commonly  found  to  be  filled  with  a  similar  secretion.  Any  attempt, 
therefore,  to  inflate  the  ear  before  this  secretion  is  removed  from  the  nose 
and  tubal  orifice  would  most  likely  result  in  failure  to  accomplish  the 
desired  end.  Only  a  small  amount  of  cocain  is  necessary  to  sufficiently 
anesthetize  the  oversensitive  membranes  and  to  render  the  introduction 
of  the  catheter  painless,  provided  it  is  applied  only  to  the  path  the 
instrument  will  traverse  during  its  correct  introduction.  The  use  of 


ACUTE  TUBOTYMPANIC  CATARRH  243 

cocain  should  be  avoided  after  the  first  treatment  in  all  cases  who  have 
nostrils  sufficiently  open  to  permit  the  ready  passage  of  the  instrument, 
provided  the  nasal  mucous  membrane  is  not  hyperesthetic.  The  first 
few  blasts  of  air  through  the  catheter  after  it  is  properly  placed  should 
not  be  with  force,  since  the  sudden  opening  of  the  tube  and  replacement 
of  the  drum  membrane  may  cause  an  unpleasant  dizziness  or  even  faint- 
ing on  the  part  of  the  patient.  With  the  auscultation  tube  in  place,  so 
that  the  operator  may  at  all  times  judge  the  effect  of  the  inflation  upon 
the  Eustachian  tube  and  tympanic  cavity,  the  air  blasts  are  given  with 
increasing  force  until  the  cavum  tympani  is  entered  and  its  normal  air 
pressure  is  restored. 

The  greatly  improved  hearing  which  immediately  results  from  the 
successful  performance  of  this  procedure  will  not  likely  prove  permanent, 
the  rule  being  that  within  a  few  hours  after  the  inflation  diminution 
begins,  and  by  the  end  of  one  or  two  days  the  patient  again  hears  almost 
if  not  quite  as  badly  as  before  the  treatment.  It  will,  therefore,  be 
necessary  to  repeat  the  operation  in  the  worst  cases  at  first  daily,  later 
every  other  day,  and  finally,  once  a  week,  as  the  necessity  for  the  inflation 
disappears,  while  the  hearing  gradually  improves,  and  at  the  end  of  two 
or  three  weeks  becomes  normal.  After  the  first  few  inflations,  when  the 
patient  is  known  to  be  improving  satisfactorily,  a  good  rule  to  follow  is 
to  request  the  patient  to  return  for  treatment  only  when  he  is  convinced 
that  the  hearing  power  is  again  decreasing.  • 

Proper  local  treatment  of  the  nasopharynx  is  scarcely  less  important 
than  the  inflation  of  the  drum  cavity.  The  author  considers  the  judic- 
ious management,  either  surgically  or  otherwise,  of  all  inflammatory 
affections  or  new  growths  which  may  be  found  in  this  region,  of  such 
great  importance  in  this  and  several  other  aural  affections,  that  a  separate 
chapter  bearing  on  the  subject  has  been  prepared,  and  to  which  the 
careful  attention  of  the  student  is  here  referred  (see  Chapter  XIX.).  At 
present  all  that  need  be  said  in  reference  to  this  treatment  is  that  a  suc- 
cessful result,  both  as  to  the  cure  of  the  present  aural  ailment  and  the  pre- 
vention of  future  attacks  of  a  similar  or  increasingly  severe  nature,  will 
depend  in  great  measure  upon  the  skill  and  judgment  with  which  the 
nasopharyngeal  and  nasal  treatment  is  carried  out. 

If  the  affection  is  seen  early  and  the  above  measures  of  inflation 
and  nasopharyngeal  treatment  are  carried  out  as  directed,  a  large 
percentage  of  all  cases  of  tubal  catarrh  will  be  cured  before  coming  to 
the  second  stage  or  that  of  tubotympanic  catarrh  with  exudate  into  the 
cavity  of  the  middle  ear.  Should,  however,  the  disease  reach  the 
tympanic  cavity,  into  which  an  exudate  takes  place,  the  treatment,  in 


244  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

addition  to  that  already  given,  will  consist  largely  of  an  effort  to  remove 
the  exudate  and  to  prevent  its  re-formation.  Two  methods  of  removing 
the  exudate  are  in  use:  First,  with  the  catheter  introduced  into  the 
Eustachian  tube  in  the  usual  way,  the  patient's  head  is  held  forward 
and  somewhat  toward  the  side  opposite  that  which  contains  the  fluid, 
when  by  means  of  air  blasts  driven  through  the  catheter,  first 
with  a  very  moderate  force,  and  later  with  a  pressure  of  15  or  20 
pounds  if  necessary,  the  air  current,  aided  by  the  position  of  the  head, 
causes  the  secretion  in  the  middle  ear  to  flow  out  through  the  Eustachian 
tube  into  the  nasopharynx  and  sometimes  to  trickle  forward  through 
the  nose.  If  the  tympanic  exudate  has  by  this  means  been  removed, 
this  fact  may  be  known  to  the  surgeon  by  an  inspection  of  the  drum 
membrane  immediately  after  the  performance,  when  the  line  denoting 
the  previous  level  of  the  exudate  will  have  been  lowered  or  completely 
obliterated,  and  the  yellowish  color  previously  imparted  by  the  con- 
tained fluid  will  have  diminished  or  completely  disappeared.  This 
degree  of  success  will  justify  a  repetition  of  the  catheter  method  of 
removal  of  the  tympanic  fluid  every  second  or  third  day  if  there  is 
a  tendency  to  its  reaccumulation.  While  this  part  of  the  treat- 
ment is  being  carried  out  the  cleansing  and  appropriate  local  appli- 
cations should  be  made  to  the  nasopharynx.  After  ten  days'  trial 
of  this  means,  if  the  exudate  is  not  thereby  removed,  or  if  at  the  first 
examination  of  the  case  the  tympanic  cavity  appears  to  be  filled  with  the 
exudate  to  the  extent  of  bulging  in  some  portion  of  the  drum  membrane, 
the  best  procedure  is  to  at  once  incise  the  drum  membrane  and  remove 
the  secretion  through  the  external  auditory  canal. 

Incision  of  the  tympanic  membrane,  or  paracentesis,  which  is  per- 
formed for  the  purpose  of  entering  the  drum  cavity  from  without  and 
of  evacuating  secretions  which  are  retained  within,  is  employed  as  a 
curative  and  diagnostic  measure  in  this  and  several  other  catarrhal  and 
inflammatory  aural  affections.  A  complete  description  of  the  procedure 
and  method  of  its  performance  is  therefore  given  here,  and  reference 
will  be  made  to  it  as  may  be  subsequently  required  for  the  proper  under- 
standing of  other  sections  of  the  work. 

Incision  of  the  drum  membrane  should  always  be  preceded  by  a 
careful  sterilization  of  the  external  auditory  meatus,  including  the 
dermoid  surface  of  the  membrane  itself.  To  accomplish  this,  a  warm 
solution  of  mercuric  bichlorid  (1:40x30)  is  sufficient  when  used  for 
syringing  the  canal,  after  which  a  stronger  solution  of  this  drug  may  be 
rubbed  into  the  roots  of  the  hairs  of  the  outer  portion  of  the  meatus  and 
into  the  skin  of  the  deeper  portion.  Hydrogen  peroxid  or  the  alcohol 


ACUTE  TUBOTYMPANIC  CATARRH  245 

and  boric  acid  solution  are  also  effective  for  this  purpose.  Since  it  is 
frequently  desirable  to  inflate  the  middle  ear,  either  by  the  Politzer 
method  or  through  the  catheter  after  the  drum  membrane  is  incised, 
it  is  also  necessary  to  spray  the  nose  and  nasopharynx  thoroughly  as  a 
part  of  the  preparation  for  the  incision. 

The  question  of  the  administration  of  an  anesthetic  arises  in  many 
cases,  for  when  the  membrana  tympani  is  inflamed,  and  the  patient  has 
already  passed  one  or  more  sleepless  nights  and  is  therefore  exhausted 
by  the  continued  and  severe  suffering,  any  additional  or  unnecessary 
pain  should,  if  possible,  be  avoided.  A  thorough  paracentesis,  when 
performed  during  the  height  of  a  middle-ear  inflammation,  is  exquisitely 
painful  for  a  few  seconds,  and  in  highly  nervous  or  sensitive  individuals 
is  regarded  as  a  severe  measure  under  all  conditions.  Therefore,  while 
this  operation  can  be  performed  upon  a  certain  few  without  serious 
complaint,  in  the  vast  majority  of  patients  requiring  it  the  operator 
should  either  benumb  the  parts  by  the  application  of  remedies  locally 
to  the  drum  membrane  or  he  should  administer  a  general  anesthetic 
to  the  patient. 

Of  the  many  local  anesthetics  that  have  been  suggested  to  prevent 
the  pain  during  paracentesis  and  other  operations  on  the  drum  mem- 
brane, the  following,  suggested  by  Gray,  of  Great  Britain,1  has  proven 
serviceable : 

R.  Cocain  cryst.,  gr.  xii-xxiv  ; 

Anilin  oil,  3J  > 

Absolute  alcohol,  3j. — M. 

After  cleansing  and  drying  the  external  auditory  meatus  the  patient 
lies  upon  a  cot  with  the  affected  ear  uppermost,  and  the  canal  is  filled 
with  the  warm  anilin-cocain  solution  which  is  allowed  to  remain  for  ten  or 
fifteen  minutes,  at  the  end  of  which  time  the  membrana  tympani  is 
usually  sufficiently  anesthetized  to  permit  of  almost  painless  operating. 
This  preparation  should  not  be  used  without  caution  in  any  case  in 
which  a  large  perforation  exists  in  the  drum  membrane,  for  the  reason 
that  should  the  tympanic  cavity  be  filled  with  the  solution  toxic  symptoms 
may  rapidly  develop,  as  in  cases  reported  by  Dupuy  (Laryngoscope, 
Oct.,  1901),  Gray  (Lancet,  Mar.,  1901),  and  St.  Clair  Thomson  (Lancet, 
Apr.,  1901). 

A  5  to  10  per  cent,  solution  of  phenol  in  glycerin  produces,  when 
applied  to  the  drum  membrane,  one  of  the  most  satisfactory  methods 
of  local  anesthesia.  The  preparation  should  be  used  exactly  as  in  the 
case  of  the  anilin-cocain  solution,  but  it  requires  more  time  to  produce 

1  Brit.  Med.  Journal,  April,  1900. 


246  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

its  full  effect.  Many  combinations  of  cocain  have  been  suggested  as 
efficient  local  anesthetics  in  aural  surgery,  but  most  of  them  are  un- 
worthy of  trial,  for  the  reason  that  cocain  will  not  be  absorbed  through 
the  dermoid  layer  of  the  drum-head.  The  author  has  experimentally 
tested  the  membrana  tympani  and  found  it  to  be  exquisitely  sensitive 
after  having  been  bathed  for  an  hour  in  a  saturated  watery  solution  of 
cocain.  No  drug  or  combination  of  drugs  has  yet  been  discovered 
which  will  safely  and  completely  anesthetize  the  inflamed  drum  mem- 
brane, and  hence  more  or  less  pain  will  be  experienced  by  the  patient 
after  the  best  of  those  suggested  has  been  properly  used.  The  prepara- 
tion, when  used  in  this  way,  very  greatly  lessens  the  pain,  but  does  not 
usually  completely  prevent  it. 

In  case  of  a  child  or  of  a  very  nervous  and  oversensitive  adult  the 
choice  of  a  general  anesthetic  is  frequently  necessary.  Because  of  the 
'  very  short  duration  of  the  operation  chloroform  is  preferable  where  not 
contra-indicated.  In  the  case  of  older  children  and  adults  the  admin- 
istration of  nitrous  oxid  is  an  ideal  method  of  securing  general  anes- 
thesia, since  it  is  both  rapid  and  safe,  and  the  patient  is  almost  imme- 
diately afterward  conscious  and  free  from  the  troublesome  nausea  which 
often  follows  the  use  of  chloroform  or  ether.  A  further  recommenda- 
tion for  the  use  of  nitrous  oxid  is  that  the  patient  sits  upright  during 
the  operation  and  the  normal  position  of  the  quadrants  of  the  membrana 
tympani  are  not  altered  from  those  most  commonly  seen  by  the  operator. 

The  parts  having  been  sterilized  and  the  anesthetic  provided  for, 
the  incision  is  made  by  means  of  a  slender,  sharp-pointed  knife  which 
may  have  either  a  straight  or  an  angular  handle  (Fig.  141).  This 
instrument  should,  of  course,  have  been  freshly  sterilized,  and  must  have 
its  point  and  cutting  edge  in  perfect  condition.  A  dull-pointed  knife 
is  unfit  for  use  and  will  cause  very  much  unnecessary  pain  when  em- 
ployed in  cases  where  only  a  local  anesthetic  has  been  used  or  perhaps 
no  anesthetic  at  all.  Under  local  anesthesia,  or  when  nitrous  oxid 
gas  is  used  as  a  general  anesthetic,  the  patient  sits  upright  in  a  chair 
and  the  head  is  supported  firmly  between  the  hands  of  an  assistant. 
The  largest  speculum  is  introduced  into  the  canal  which  will  give  a  good 
view  of  the  drum  membrane,  and  this  latter  structure  is  then  clearly 
illuminated  by  means  of  reflected  light  from  the  head-mirror.  The  knife 
used  for  making  the  incision  is  slowly  advanced  into  the  external  auditory 
meatus  until  its  point  is  near  the  membrana  tympani,  when  it  is  suddenly 
thrust  through,  and  a  cut  is  made  upward  or  downward  for  the 
required  distance  before  the  blade  is  withdrawn  (Fig.  142).  Should 
the  patient  be  in  the  recumbent  position,  the  operator  has  only  to  re- 


ACUTE  TUBOTYMPANIC  CATARRH 


247 


member  the  changed  position  of  the  landmarks  from  that  in  which 
he  is  accustomed  to  seeing  them,  and  to  operate  accordingly. 

The  particular  portion  or  quadrant  of  the  drum  membrane  which 
should  be  incised  in  any  given  case  and  also  the  length  of  the  incision 
depends  upon  the  character  of  the  disease  which  requires  the  operation, 
and  upon  whether  or  not  there  is  fluid  in  the  tympanic  cavity  in  sufficient 
quantity  to  cause  bulging  of  some  part  of  the  membrane.  Thus,  in 


Fir..  142. — LINE  OF  INCISION  FOR  EVACUATION 
OF  EXUDATE. 


FIG.  140. — PARACENTESIS 
NEEDLE. 


FIG.  141. — PARACENTESIS 
KNIFE. 


FIG.  143. — LINES  OF  INCISION    FOR   SEVERAL 
DIFFERENT  TYMPANIC  CONDITIONS. 


severe  inflammation  of  the  tympanic  attic,  where  it  is  desirable  to  secure 
free  depletion  of  the  mucous  lining  of  that  region,  it  is  necessary  to 
make  the  incision  in  one  of  the  superior  quadrants,  whereas  if  the 
disease  be  confined  to  the  atrium  the  incision  should  be  made  in  one  of 
the  inferior  quadrants.  However,  whatever  may  be  the  causative 
disease,  if  the  result  has  been  an  effusion  of  serum,  an  oversecretion  of 
mucus,  or  a  collection  of  pus  which  causes  a  decided  bulging  of  some 
portion  of  the  tympanic  membrane,  then  the  incision  should  be  made 


248  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

so  as  to  divide  the  swollen  area  and  to  include  its  highest  point,  as  shown 
in  Fig.  142. 

The  extent  of  the  incision  is  a  matter  of  judgment  in  each  individual 
case,  and  must  be  governed  by  the  severity  of  the  disease,  the  pathologic 
condition  which  is  present  in  the  tympanic  cavity,  and  the  particular 
end  that  is  desired  to  be  accomplished.  Since  large  incisions  heal  as 
rapidly  as  small  ones,  and  since  the  efficiency  of  a  paracentesis  usually 
depends  upon  the  freedom  with  which  it  is  made,  it  is  better  to  err  on 
the  side  of  making  the  cut  too  long  rather  than  too  short.  A  mere 
puncture  of  the  membrana  with  the  paracentesis  needle  (Fig.  140)  or 
with  the  point  of  the  knife  is  not  sufficient.  When  the  atrium  is  filled 
with  fluid  the  knife  may  be  entered  at  a  point  posterior  to  the  short 
process  of  the  malleus,  just  below  the  posterior  fold  and  near  the  tympanic 
ring,  and  with  the  cutting  edge  turned  downward  be  carried  parallel 
to  the  ring  to  the  inferior  pole  of  the  membrane  (Fig.  143,  A  B).  Or  in 
case  the  attic  is  affected  and  its  mucous  lining  is  violently  inflamed,  the 
edge  of  the  knife  may  be  turned  upward,  and  the  cut  be  made  as  far  as 
the  upper  pole  of  the  ring  and  then  carried  outward  through  the  skin 
of  the  posterosuperior  wall  of  the  external  meatus  (Fig.  143,  E  F).  The 
depth  to  which  the  point  of  the  knife  should  be  carried  varies  also  ac- 
cording to  the  nature  of  the  disease  within  the  tympanum.  When  the 
incision  is  made  to  evacuate  fluid  which  is  the  result  of  a  tubotympanic 
congestion  it  is  not  essential  to  incise  the  mucous  lining  of  the  inner 
tympanic  wall  at  the  same  time  that  the  drum  membrane  is  divided; 
whereas,  if  there  is  in  addition  to  a  collection  of  fluid  an  intense  engorge- 
ment of  this  membrane,  and  depletion  of  the  latter  is  desired,  then  the 
knife  should  be  entered  deeply  enough  to  include  both  the  tympanic 
membrane  and  the  mucous  covering  of  the  inner  tympanic  wall. 

The  recuperative  power  of  the  drum  membrane  is  nearly  always 
very  active  and  not  infrequently  surprising  in  this  respect.  Hence 
when  injured  by  a  clean  cut,  and  the  wound  is  kept  free  from  subsequent 
infection,  a  union  of  the  severed  parts  takes  place  within  one  or  two  days, 
or  just  as  soon  as  the  exudate,  or  disease,  within  the  tympanic  cavity 
will  permit.  After  a  free  incision  of  the  membrana  tympani,  therefore, 
the  danger  is  that  the  wound  will  heal  too  soon  rather  than  not  at  all. 

After  a  free  incision  of  the  drum  membrane  in  case  of  the  accumula- 
tion of  exudate  during  the  course  of  a  tubotympanic  congestion,  a 
small  amount  may  pour  through  the  opening  into  the  external  auditory 
meatus  immediately,  provided  the  contained  fluid  be  of  a  serous  nature, 
but  if  it  is  thick  and  tenacious,  only  a  bead  of  the  exudate  may  protrude 
through  the  gaping  incision,  and  none  will  subsequently  be  found  in 


ACUTE  TUBOTYMPANIC  CATARRH  249 

the  external  meatus.  In  either  case  it  will  be  necessary  to  employ  in- 
flation for  the  purpose  of  completely  dislodging  the  exudate  and  of 
clearing  the  tympanic  cavity.  Catheterization  or  politzerization  should, 
therefore,  be  immediately  performed  after  the  paracentesis  and  should 
be  repeated  until  all  the  exudate  is  driven  through  the  opening  into  the 
auditory  canal.  It  is  sometimes  impossible,  even  by  vigorous  inflation,  to 
dislodge  all  of  the  mucus,  in  which  case  resort  may  be  had  to  Siegel's 
otoscope  (Fig.  97),  which,  when  employed  for  this  purpose,  should  be 
used  as  a  suction  apparatus,  by  which  means  the  remaining  exudate 
can  be  effectively  dislodged  and  sucked  into  the  auditory  meatus.  It 
has  been  proposed  by  some  authors  to  wash  the  exudate  out  of  the 
tympanic  cavity  by  means  of  an  antiseptic  fluid  injected  through  the 
catheter  by  way  of  the  Eustachian  tube,  allowing  it  then  to  flow  out 
through  the  incision  in  the  drum  membrane  into  the  auditory  canal. 
This  procedure,  as  well  as  that  of  syringing  the  external  auditory  meatus, 
has  been  proved  to  be  harmful  and  should,  therefore,  not  be  practised. 
The  exudate  usually  reaccumulates,  and  the  inflation  of  the  middle  ear 
and  suction  with  Siegel's  apparatus  will,  therefore,  need  repeating,  .at 
first  every  day,  then  every  other  day,  and  finally  only  when  the  exudate 
returns  in  quantity  sufficient  to  impair  the  hearing.  At  the  same  time 
that  these  treatments  are  given  the  nasopharynx  must  receive  attention, 
and  all  inflammation  or  growths  that  are  present  should  be  skillfully 
managed.  The  general  health  of  the  individual  may  also  be  such  as  to 
require  the  administration  of  tonics,  the  regulation  of  the  diet,  or  a 
change  of  environment  to  one  that  is  less  productive  of  frequent  cold- 
taking. 


CHAPTER  XXII 

ACUTE  CATARRHAL  OTITIS  MEDIA 

THIS  disease  is,  as  the  name  indicates,  an  actual  inflammation  of 
the  mucous  lining  of  the  tympanic  cavity.  Confusion  as  to  the  exact 
meaning  of  the  terms  used  in  the  description  of  the  acute  diseases  of  the 
middle  ear  is  apt  to  arise  unless  the  student  bears  constantly  in  mind 
the  pathology  of  each.  In  the  preceding  chapter  a  description  of  the 
acute  congestive  middle-ear  affections  was  given,  and  it  should  now  be 
recalled  that  the  symptoms  and  objective  signs  accompanying  them 
were  not  those  which  would  indicate  diseases  of  an  inflammatory  nature. 
While  otitis  media  of  the  catarrhal  variety  is  sometimes  the  result  of 
a  preceding  tubotympanic  congestion,  it  is  usually  an  independent 
affection,  behaves  differently  throughout  its  course,  is  in  every  way  a 
more  severe  disease,  and  one  that  is  dependent  upon  a  more  active  form 
of  infection  of  the  cavity  by  one  or  more  varieties  of  pathogenic  bacteria. 

Causation. — All  the  causes  that  have  been  enumerated  as  productive 
of  tubotympanic  catarrh  are  also  active  as  etiologic  factors  in  this  disease. 
Thus,  colds  in  the  head,  nasopharyngitis,  and  indeed  the  presence  of  all 
varieties  of  inflammation  or  new  growths  in  the  nose  or  nasopharyngeal 
space,  may  be  considered  as  predisposing  causes.  Stoppage  of  the  nose 
or  throat  by  growths  or  inflammatory  swelling  of  the  mucous  membrane 
in  this  locality  is  productive  of  middle-ear  complication,  first,  because 
these  conditions  of  the  upper  air  tract  favor  the  growth  of  bacteria  in 
a  neighborhood  immediately  adjoining  the  middle  ear;  second,  the 
presence  of  such  growths  or  inflammations  favors  an  extension  of  venous 
congestion  in  the  Eustachian  tube  and  the  mucous  lining  of  the  middle 
ear,  and  third,  the  obstruction  of  the  pharynx  and  nostrils,  together 
with  the  presence  of  the  ropy  secretion,  requires  that  the  individual 
blow  his  nose  with  undue  force  in  order  to  clear  the  respiratory  spaces; 
and  this  force  is  often  great  enough  to  blow  some  of  the  infected  mucus 
through  the  Eustachian  tube  into  the  middle  ear,  the  inevitable  result 
of  which  is  that  the  disease  under  consideration  is  at  once  set  up.  Faulty 
methods  of  using  the  nasal  douche,  either  by  the  physician  or  the  patient 
himself,  is  sometimes  responsible  for  the  disease.  Patients  who  acciden- 
tally become  strangled  while  gargling  the  throat,  or  from  accidentally 

250 


ACUTE    CATARRHAL    OTITIS    MEDIA  251 

getting  water  into  the  mouth  while  bathing,  may  in  their  sudden  and 
violent  efforts  to  expel  the  fluid  force  some  of  it  through  the  Eustachian 
tube  into  the  middle  ear.  Watery  solutions  of  all  kinds,  if  forced  from 
any  reason  to  enter  the  tympanic  cavity,  invariably  set  up  an  otitis 
media,  and  the  physician  should,  therefore,  bear  in  mind  certain  rules 
concerning  the  proper  method  of  nasal  douching  when  personally 
employing  this  plan  of  nasal  cleansing.  Explicit  directions  should 
always  be  given  for  the  methods  of  employment  of  the  nasal  douche 
should  the  patient  be  directed  to  use  this  as  a  method  of  home  treat- 
ment. (See  chapter  on  Nasal  Treatment  of  Ear  Diseases,  p.  202.)  The 
milder  forms  of  measles,  scarlet  fever,  la  grippe,  and  other  infectious 
diseases  which  nearly  always  affect  the  throat  at  the  same  time,  are 
also  frequent  causes  of  acute  catarrhal  otitis  media,  the  latter  disease 
following  as  a  complication,  and  is  brought  about  in  exactly  the  same 
manner  that  the  pathogenic  bacteria  are  caused  to  enter  the  drum 
cavity — namely,  as  a  result  of  the  entrance  of  pathogenic  bacteria  into 
the  tympanum.  The  more  violent  varieties  of  the  infectious  diseases 
are  usually  followed  by  acute  purulent  otitis  media,  which  will  be 
described  in  the  next  chapter. 

Pathology. — In  acute  catarrhal  otitis  media  there  is  a  general  hyper- 
emia  of  the  middle-ear  mucous  membrane.  The  mucous  membrane  is 
swollen  through  enlargement  of  its  vessels,  serous  and  round-cell  infiltra- 
tion takes  place,  and  there  may  be  more  or  less  exudate  either  serous, 
mucous,  or  seromucous  lying  on  the  surface  of  the  mucous  membrane. 
The  air  spaces  are  lessened  through  the  swelling  of  the  mucous  membrane, 
the  stapes  may  be  hidden  in  the  vestibular  window,  or  the  niche  to  the 
cochlear  window  may  be  occluded.  The  catarrhal  secretion  is  a  combi- 
nation of  inflammatory  exudate  and  transudate.  If  the  exudate  is  serous, 
it  is  clear  and  thin;  if  mucoid,  it  is  thick  and  even  tough,  so  that  it  can 
be  drawn  out  by  forceps.  This  disease  is  a  combination  of  a  tubo- 
tympanic  catarrh  and  an  inflammation  not  intense  enough  to  cause 
necrosis  of  the  middle-ear  tissue,  as  in  acute  suppurative  otitis  media. 

Symptoms. — Deep-seated  pain  in  the  ear  is  one  of  the  earliest 
as  well  as  the  most  pronounced  symptom.  When  the  inflammation 
has  reached  its  height  the  pain  is  of  a  lancinating,  tearing,  and  alto- 
gether unbearable  nature.  During  the  day,  when  the  patient  may  en- 
deavor to  interest  himself  in  his  business  affairs,  less  complaint  is  made, 
but  during  the  night,  and  especially  if  the  recumbent  position  is  assumed, 
the  suffering  is  greatly  increased,  sleep  is  impossible,  and  the  patient 
frequently  walks  the  floor,  holds  his  head  between  his  hands,  and  cries 
aloud.  There  are  usually  intervals  in  which  the  pain  is  less  severe, 


252  THE   PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 

but  upon  swallowing,  coughing,  or  belching  a  lancinating  pain  shoots 
to  the  ear  and  the  paroxysm  of  intense  suffering  is  again  renewed. 
Attempts  to  blow  the  nose  forcibly  will  also  bring  on  a  sharp  pain  which 
seems  to  the  patient  to  shoot  from  the  nasopharynx  into  the  depths  of 
the  ear.  While  in  the  beginning  the  pain  usually  centers  in  the  middle 
ear,  it  sometimes  radiates  over  the  temporal  region,  to  the  teeth,  or  it 
may  even  simulate  a  trigeminal  neuralgia. 

Pain,  or  at  least  a  feeling  of  soreness,  is  present  in  the  space  between 
the  tip  of  the  mastoid  process  and  the  ramus  of  the  lower  jaw — the 
external  site  of  the  pain  corresponding  to  the  position  and  direction  of 
the  Eustachian  tube  within.  Pressure  over  this  area  frequently  elicits 
considerable  tenderness.  Except  in  very  severe  cases,  when  the  mastoid 
antrum  and  cells  are  simultaneously  infected,  little  or  no  tenderness 
and  no  swelling  can  be  detected  over  the  mastoid  region.  The  auricle 
can  be  freely  moved  and  the  external  canal  may  be  straightened  by 
the  examiner  preparatory  to  the  insertion  of  the  aural  speculum, 
without  causing  the  patient  the  slightest  increase  of  pain. 

The  hearing  is  greatly  impaired.  Beginning  with  a  feeling  of 
stuffiness  in  the  ear,  as  the  inflammation  develops  and  the  exudate 
takes  place,  the  function  becomes  rapidly  affected  until  within  a  few 
hours  the  degree  of  deafness  is  usually  quite  marked.  Tinnitus  aurium 
and  high-pitched  cracking  sounds  due  to  the  passage  of  air  through  the 
inflamed  Eustachian  tube  into  the  fluid  of  the  middle  ear  are  also 
symptoms,  but  complaint  concerning  these  will  scarcely  be  made  while 
the  pain  in  the  ear  is  at  its  height.  After  a  rupture  of  the  drum  mem- 
brane has  taken  place  and  subsidence  of  the  aural  pain  has  occurred, 
the  chief  complaint  of  the  patient  is  frequently  of  the  subjective  head 
noises.  These  noises  are  due  to  the  increased  tension  of  the  labyrinthine 
fluids  produced  partly  by  the  presence  of  the  exudate  within  the  middle 
ear,  and  partly  by  the  intratympanic  vascular  distention  which  compli- 
cates the  changes  in  the  middle  ear. 

The  temperature  is  normal  or  but  slightly  elevated  in  the  uncom- 
plicated cases  occurring  in  adults.  If  the  otitis  media  is  the  result  of 
an  infectious  general  disease,  like  scarlatina  or  measles,  the  temperature 
may  reach  103°  F.  or  even  higher.  Should  mastoiditis  set  up  or  should 
any  of  the  intracranial  complications  arise,  the  temperature  will  be 
affected  according  to  the  particular  complication  that  supervenes. 
(For  symptoms  of  these  complications  see  Chaps.  XXXII.-XXXVIII.) 

Rupture  of  the  drum-head  occurs  at  some  period  of  the  disease  in 
the  vast  majority  of  all  cases.  After  the  suffering  has  continued  with 
more  or  less  intensity  for  from  one  to  three  days,  the  drum  membrane 


ACUTE   CATARRHAL    OTITIS    MEDIA  253 

gives  way  and  a  discharge  of  a  seromucous  fluid  takes  place  into  the 
auditory  canal.  Rarely  a  rupture  may  take  place  within  twelve  hours 
after  the  beginning  of  the  disease,  but  the  perforation  may  also  occur 
as  late  as  three  days  after  the  onset  of  the  severe  pain ;  or  a  rupture  may 
not  occur  at  all.  In  the  latter  instance  the  collection  of  exudate  within 
the  tympanum  may  escape  through  the  Eustachian  tube,  or  it  may 
remain  for  an  indefinite  period,  to  be  finally  absorbed,  to  become  or- 
ganized, and  form  connective-tissue  adhesions  between  the  membrana 
tympani  and  some  portion  of  the  inner  wall  of  the  tympanum,  or  the 
ossicles  may  become  first  imbedded  and  finally  ankylosed  by  the  deposit 
of  new  tissue  about  them. 

The  general  appearance  of  the  patient  is  usually  one  that  indicates 
great  suffering.  After  one  or  more  sleepless  nights,  during  which  the 
pain  has  been  severe  and  perhaps  incessant,  the  strongest  individual 
may  show  evidence  of  great  prostration,  and  even  those  having  great 
fortitude  will  exhibit  signs  of  the  greatest  cowardice  toward  further 
pain.  After  rupture  of  the  drum  membrane  takes  place  the  pain  is 
usually  much  lessened,  the  patient  falls  into  a  long  sleep,  the  appetite, 
which  was  previously  lost,  quickly  returns,  and  the  patient  speedily 
enters  upon  the  stage  of  convalescence.  In  some  cases,  however,  the 
pain  continues  after  the  rupture  takes  place,  and  this  fact  is  usually 
evidence  that  the  opening  through  the  drum  membrane  is  too  small, 
and  that  the  drainage  from  the  tympanic  cavity,  is,  therefore,  insufficient. 

The  appearance  of  the  drum  membrane,  as  seen  at  the  physical 
examination  of  the  ear,  varies  with  the  stage  of  the  disease  at  which 
the  examination  is  made.  During  the  first  few  hours  after  the  onset  of 
the  inflammation  a  redness  will  be  visible  along  the  handle  of  the  malleus, 
which,  if  observed  later,  will  be  found  to  have  spread  over  the  greater 
portion  or  even  the  whole  of  the  membrane,  and  to  have  become  a 
uniform,  cherry-red  color.  At  this  latter  period  the  individual  injected 
vessels  cannot  be  seen.  The  landmarks,  with  the  possible  exception 
of  the  short  process  of  the  malleus,  will  be  found  to  have  disappeared, 
and  the  whole  fundus  presents  an  inflammatory  state  in  which  it  is  not 
always  easy  to  make  out  the  ending  of  the  walls  of  the  external  auditory 
meatus  and  the  beginning  of  the  membrana  tympani.  Very  soon  the 
exudate  takes  place  into  the  tympanic  cavity,  and  this  is  shown  during 
the  otoscopic  examination  by  the  bulging  of  some  portion  of  the  drum 
membrane  which  it  causes.  The  greatest  bulging  is  most  frequently 
seen  in  the  upper  and  posterior  portion,  although  the  whole  membrane 
often  bulges  to  a  less  degree,  and  either  of  the  lower  quadrants  may  be 
most  greatly  affected  in  this  respect.  Since  in  the  purulent  variety  of 


254  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

acute  otitis  media  the  bulging  is  usually  more  limited  in  extent,  and 
is  most  usually  seen  in  the  extreme  uppermost  portion  of  the  mem- 
brane, the  position  of  the  point  of  greatest  bulging  becomes  a  feature  in 
the  differential  diagnosis  of  the  two  diseases.  Occasionally  the  postero- 
superior  segment  is  bulged  outward  in  the  form  of  a  sac,  the  lowermost 
portion  of  which  is  filled  with  exudate.  Instances  have  been  recorded 
in  which  such  a  protruding  pouch  has  been  observed  to  fill  the  postero- 
superior  portion  of  the  external  auditory  meatus,  and  even  to  appear 
as  a  polypoid-like  mass  at  the  orifice  of  the  audi- 
tory meatus  (Fig.  144). 

After  spontaneous  perforation  of  the  drum 
membrane  has  taken  place,  the  external  auditory 
meatus  is  found,  upon  inspection,  to  contain  more 
or  less  serous,  seromucous,  or  serosanguineous 
discharge,  which,  if  untreated,  or  only  badly 
treated,  will  very  rapidly  become  mucopurulent 

FIG.    144.  —  SAGGING    OF 

MEMBRANE     or  purulent.     The  presence  of  a  mucous  or  sero- 


mucous  discharge  is  evidence  of  the  occurrence 
of  a  perforation  in  the  drum  membrane,  and  the 
physical  examination  should  be  partially  directed  to  the  discovery 
of  its  location  and  extent.  Occurring  as  the  result  of  an  acute 
catarrhal  otitis  media  such  a  rupture  is  most  frequently  found  in  the 
lower  half  of  the  membrane,  either  in  the  postero-inferior  quadrant  just 
below  the  umbo,  or  in  the  antero-inferior  quadrant  over  the  site  of  the 
tympanic  entrance  of  the  Eustachian  tube.  It  is  not  always  an  easy 
matter  to  locate  a  small  perforation  during  the  height  of  the  inflammation 
when  every  surrounding  tissue  is  infiltrated,  and  the  normally  small 
area  of  the  fundus  is  thereby  still  more  greatly  encroached  upon.  If 
the  exudate  is  small  in  quantity,  it  may  be  seen  pouring  through  the 
perforation  or  a  small  bead  of  the  material  may  be  seen  protruding 
through  the  opening,  at  which  point  a  pulsation  synchronous  with  the 
heart-beat  may  be  observed.  If  the  secretion  is  profuse  and  pours 
through  the  rupture  in  an  amount  sufficient  to  fill  the  external  auditory 
canal  it  may  be  absorbed  by  the  insertion  of  a  cylinder  of  sterile  cotton 
into  the  bottom  of  the  external  auditory  meatus,  or  it  may  be  washed 
away  by  syringing,  after  which,  if  the  examination  of  the  drum  membrane 
is  made  immediately,  the  location  of  the  perforation  may  often  be  made 
out.  If  the  examination  of  the  drum  membrane  is  continued,  while  at 
the  same  time  the  patient  performs  the  Valsalva  inflation,  or  while  an 
assistant  performs  inflation  by  the  Politzer  or  catheter  method,  the 
observer  will  note  the  exit  of  air-bubbles  at  the  point  of  rupture.  He 


ACUTE   CATARRHAL   OTITIS    MEDIA  255 

will  also  often  be  able  to  hear  at  the  instant  the  inflation  is  performed 
a  hissing  sound  due  to  the  escape  of  air  through  the  opening  in  the 
tympanic  membrane. 

It  is  of  vastly  more  importance  to  determine  the  size  of  the  perforation 
rather  than  its  location,  for  the  reason  that  the  subsequent  treatment 
will  depend  in  no  small  measure  upon  whether  or  not  the  opening  is 
sufficiently  large  to  provide  ample  drainage  to  the  inflamed  cavities  of 
the  middle  ear. 

The  diagnosis  should  be  readily  made  when  the  examiner  considers 
the  symptoms  in  connection  with  the  physical  examination  of  the  mem- 
brana  tympani  itself.  The  chief  points  upon  which  the  diagnosis  will 
be  based  are :  the  acute  pain  in  the  ear  with  accompanying  deafness  and 
tinnitus,  in  a  case  where  examination  of  the  fundus  of  the  ear  shows  a 
uniformly  reddened  and  infiltrated  drum  membrane  which  is  also 
bulging  and  perhaps  perforated.  This  disease  must  be  distinguished 
from  acute  tubotympanic  catarrh  and  from  the  acute  suppurative  dis- 
eases of  the  middle  ear.  The  differential  diagnosis  is  given  in  a  com- 
prehensive form  at  the  end  of  the  next  chapter  (see  p.  277). 

Prognosis. — The  ultimate  result  of  acute  catarrhal  otitis  media  is 
nearly  always  favorable  in  persons  who  were  previously  in  good  health, 
and  whose  environment  is  subsequently  good.  This  is  especially  true 
of  cases  that  are  seen  early  and  are  skilfully  treated  until  all  the  dis- 
eased parts  have  resumed  their  normal  condition.  When  the  disease 
follows  an  infectious  fever  or  is  the  result  of  a  tuberculous  affection,  the 
prognosis  is  not  so  good,  and  the  discharge  is  apt  to  become  first 
purulent  and  then  ultimately  chronic.  In  anemic,  underfed,  and  poorly 
housed  individuals  the  discharge  may  also  become  chronic.  Children 
who  are  affected  with  adenoids  and  adults  who  suffer  from  chronic  naso- 
pharyngitis  or  from  obstructive  nasal  growths  are  subject  to  recur- 
rences of  the  aural  inflammation  during  the  damp  and  changeable 
seasons  of  the  year.  In  such  instances  the  pathologic  condition  of 
the  nose  and  nasopharynx  acts  as  a  continued  menace  to  the  ear,  and 
each  attack  of  the  tympanic  inflammation  predisposes  the  patient  to 
another,  until  after  a  period  of  years  the  structures  of  the  ear  are  hope- 
lessly damaged.  Mastoiditis  rarely  occurs  in  this  disease,  but  when 
it  complicates  the  tympanic  ailment  the  dangers  incident  to  this  affection 
are  added  to  the  original  disease.  Intracranial  extension  with  resulting 
meningitis,  brain  abscess,  or  infective  thrombosis  of  the  lateral  sinus 
is  still  more  rarely  met  with,  and  when  one  of  these  complications  does 
take  place  it  is  the  result  of  transmission  of  the  infective  material  from 
the  middle  ear  or  mastoid  to  the  cranial  cavity  through  the  medium 


256  THE    PRINCIPLES   AND   PRACTICE    OF   OTOLOGY 

of  the  blood  or  lymph  streams,  and  not,  as  is  the  case  in  chronic  suppura- 
tive  otitis,  through  open  channels  that  have  been  provided  by  the  necrosis 
of  the  intervening  osseous  structures. 

Treatment. — Since  the  patient  is  most  usually  seen  for  the  first 
time  after  the  pain  has  become  severe,  the  relief  of  the  suffering  becomes 
the  first  and  most  urgent  duty.  This  is  most  speedily  and  effectively 
accomplished  by  the  administration  of  morphin  hypodermically,  if 
the  patient  be  an  adult,  or,  in  the  case  of  a  child,  an  appropriate-sized 
dose  of  deodorized  tincture  of  opium  given  per  orum.  It  is  safest  to 
give  paregoric  to  infants.  Whatever  form  of  anodyne  is  prescribed 
should  be  given  in  a  sufficiently  large  dose  to  completely  relieve  the  pain 
and  to  secure  the  much-needed  rest  for  the  patient.  The  continued 
administration  of  opiates  is  objectionable,  and  therefore  just  as  soon 
as  the  patient  is  once  relieved,  active  means  of  combating  or  aborting 
the  inflammation  should  be  instituted.  If  the  individual  is  robust  or 
plethoric,  the  administration  of  saline  draughts  should  be  begun  at  once 
and  repeated  until  several  large  watery  stools  are  produced.  Local 
depletion  is  an  effectual  means  of  relieving  the  pain  and  of  lessening  the 
intratympanic  congestion,  provided  it  be  practised  early  and  before 
the  exudate  has  taken  place  into  the  tympanic  cavity.  (See  p.  125  for 
a  description  of  the  methods  and  benefits  to  be  derived  from  local 
depletion.)  In  adults  not  fewer  than  three  natural  leeches  should  be 
applied,  and  if  the  artificial  leech  is  used,  from  2  to  4  ounces  of  blood 
should  be  withdrawn  from  the  postauricular  region. 

When  the  inflammation  of  the  tympanic  mucous  membrane  is  of 
a  milder  nature  and  the  accompanying  pain  less  severe,  sufficient  relief 
may  often  be  obtained  by  the  use  of  local  applications  which  are  made 
directly  to  the  drum  membrane  and  supplemented  by  the  employment 
of  dry  heat  applied  continuously  to  the  affected  side  of  the  head.  Among 
the  most  useful  remedies  to  be  applied  directly  to  the  drum  membrane 
for  the  relief  of  the  pain  may  be  mentioned  the  phenol-glycerin  solution, 
in  the  proportion  of  10  per  cent,  of  the  former  and  90  per  cent,  of  the 
latter.  This  can  be  most  effectually  applied  to  the  affected  part  by 
twisting  a  cone  of  cotton  on  the  end  of  a  small  applicator  (Fig.  204), 
saturating  the  cotton  in  the  solution  of  phenol-glycerin,  and  then  holding 
the  same  over  a  flame  until  it  is  heated  to  the  greatest  degree  of  toleration 
when  tested  upon  the  back  of  the  hand.  After  thus  properly  preparing 
and  heating  the  medicated  cotton  cone,  it  is  quickly  removed  from  the 
applicator,  seized  between  the  jaws  of  the  slender  aural  dressing-forceps, 
and  before  it  has  time  to  cool  is  quickly  inserted  to  the  bottom  of  the 
external  auditory  meatus  where  it  is  allowed  to  remain  with  the  large 


ACUTE    CATARRHAL   OTITIS    MEDIA  257 

end  of  the  cone  of  glycerinated  cotton  resting  directly  against  the  outer 
surface  of  the  drum  membrane,  while  the  caudal  end  projects  slightly 
from  the  meatus,  so  that  it  may  be  easily  removed  at  any  time  by  the 
attendant  or  by  the  patient  himself.  If  this  cotton  cone  is  prepared 
so  as  to  fit  the  meatus  snugly,  if  it  is  previously  heated  to  the  proper 
degree,  and  is  then  accurately  inserted  against  the  drum  membrane, 
it  acts  beneficially  in  two  ways:  first,  from  the  direct  and  continuous 
application  of  the  heat,  and  from  the  action  of  the  anesthetic  qualities 
of  the  carbolic  acid,  the  pain  is  relieved;-  and  second,  the  presence  of 
the  glycerin  in  contact  with  the  inflamed  surface  causes  a  transudate 
of  serum  in  the  direction  of  the  auditory  canal  which  is  sometimes 
notably  efficient  in  unloading  the  congested  blood-vessels  of  the  drum 
membrane  and  in  lessening  the  quantity  of  the  exudate  within  the 
tympanic  cavity.  This  glycerinated  tampon  may  be  left  in  the  auditory 
canal  for  several  hours,  provided  there  is  no  return  of  the  acute  pain. 
Immediately  after  its  insertion  dry  heat  in  the  form  of  the  hot-water 
bottle  or  Japanese  stove  should  be  made  over  the  external  surface  of 
that  side  of  the  head.  The  author  has  observed  but  slight  relief  from 
the  instillation  into  the  external  auditory  canal  of  such  fluids  as  laudanum 
and  sweet  oil,  which  preparation  is  so  commonly  used  by  the  laity  for 
the  relief  of  earache;  nor  has  any  appreciable  benefit  been  obtained 
from  the  instillation  of  solutions  of  cocain  even  when  of  considerable 
strength.  Any  non-irritating  solution  if  instilled  warm  into  an  aching 
ear  will  give  some  degree  of  relief,  and  the  reputation  which  many  ear 
solutions  have  acquired  for  the  relief  of  earache  is  due  to  the  fact  that 
they  are  always  instilled  while  warm  rather  than  to  any  anesthetic  or 
anodyne  property  of  the  drugs  which  they  contain.  Plain  unmedicated 
water,  when  instilled  after  it  has  been  heated  to  the  proper  temperature, 
will  usually  prove  equally  as  efficient  for  the  relief  of  aural  pain  as  any  of 
the  more  complicated  and  expensive  combination  of  drugs  which  form 
the  basis  of  ear-drops.  The  insertion  of  a  Richards'  aural  bougie  into 
the  external  auditory  meatus  has  been  helpful,  particularly  in  the  case 
of  earache  in  very  young  children.1 

1  The  formula  for  this  bougie  is  as  follows  : 

R.     Acidi  carbolici,  tTL  vij; 

Extract  opii  fl.,  TTL  vj; 

Cocaini,  grs.  iij; 

Atropin  sulphate,  grs.  iij; 

Aquae,  V([  Kj; 

Gelatini,  grs.  xviij; 

Glycerini,  grs.  clviij. — M. 

To  make  42  bougies.     At  the  moment  the  bougie  is  to  be  used  it  is  dipped  into  water  as 

hot  as  the  hand  will  bear.      This  renders  it  elastic,  easy  of  insertion,  and  adds  the 
17 


258  THE   PRINCIPLES   AND    PRACTICE    OF   OTOLOGY 

Should  the  foregoing  measures  fail  to  relieve  the  pain  and  abort  the 
inflammation,  and  should  it  be  found  upon  examination  of  the  drum 
membrane  that  an  exudate  has  taken  place  into  the  tympanic  cavity, 
incision  of  the  drum  membrane  should  be  performed  at  once.  In  case 
the  bulging  is  greatest  over  the  posterior  portion  of  the  membrane,  the 
knife  should  be  inserted  just  below  the  posterior  fold,  near  the  tympanic 
margin,  and  should  then  be  carried  downward  parallel  with  the  tympanic 
ring  to  its  postero-inferior  portion  (see  Fig.  143,  A  B).  Since  the  exudate 
within  the  tympanic  cavity  is  usually  thin,  under  pressure  it  immediately 
pours  through  the  slit  thus  made  in  the  membrana,  and  often  in  sufficient 
quantity  to  appear  at  the  concha  almost  before  the  withdrawal  of  the 
paracentesis  knife.  The  bulging  may  occur  in 
any  quadrant,  and  wherever  located,  the  incision 
must  be  made  in  such  direction  and  position 
as  to  include  it,  and  consequently  to  be  most 
favorable  to  free  drainage  (Fig.  145).  When  the 
incision  is  performed  early,  and  therefore  during 
the  height  of  the  inflammation  of  the  tympanic 
FIG.  i4S.— SHOWING  LINE  mucous  lining,  more  favorable  results  will  be 

LiEiiSr1'  obtained  if  the  p°int  of  the  knife  is  p»shcd  inward 

to  a  sufficient  depth  to  include  the  mucous  mem- 
brane of  the  inner  tympanic  wall  in  the  cut.  A  free  hemorrhage  will 
take  place  as  the  result  of  this  incision  of  the  mucous  membrane,  and 
as  a  consequence -the  congested  parts  are  depleted,  the  tension  of  the 
vessels  is  relieved,  and  the  swelling  of  the  mucous  membrane  is  greatly 
reduced. 

The  turbid  seromucous  discharge  which  follows  the  incision  con- 
tains pathogenic  bacteria  of  a  low  grade  of  virulence,  and  hence  if  the 
drum  cavity  is  not  subsequently  infected  from  the  auditory  meatus 
through  the  incised  wound  in  the  membrane  or  from  the  nasopharynx 
through  the  Eustachian  tube,  the  case  will  progress  speedily  toward 
recovery.  The  first  duty  of  the  physician  following  a  paracentesis  is, 
therefore,  to  provide  as  much  as  possible  against  the  occurrence  of  such 
an  infection  from  without.  It  is  presumed,  of  course,  that  the  external 
auditory  meatus  has  been  thoroughly  sterilized  before  the  drum  mem- 
brane is  incised,  and  it  only  remains  to  keep  it  in  this  state  during  the 
subsequent  period  of  discharge  and  the  healing  of  the  wound.  To 

valuable  quality  of  heat  in  a  form  available  for  local  application.  The  bougie  should 
be  inserted  deeply  into  the  auditory  canal,  where  it  dissolves  and  allows  the  several  in- 
gredients of  which  it  is  composed  to  come  into  direct  contact  with  the  membrana  tym- 
pani.  A  pledget  of  cotton  should  be  inserted  into  the  meatus  to  retain  the  bougie,  and 
the  hot-water  bottle  should  then  be  applied  over  the  auricle  and  affected  side  of  the  head. 


ACUTE    CATARRHAL   OTITIS    MEDIA 


259 


do  this  effectively  is  not  so  simple  a  measure  as  might  at  first  be  supposed, 
for  unless  the  subsequent  dressings  be  made  in  a  perfectly  aseptic 
dressing  room  it  is  easy  to  carry  an  infection  to  the  middle  ear  upon 
either  the  gauze  or  instruments  that  are  afterward  used.  However, 
if  the  instruments,  operator's  hands,  and  the  external  auditory  meatus 
of  the  patient  are  sterile,  and  reasonable  care  be  taken  not  to  handle 
the  patient's  heacf  or  objects  in  the  treatment  room,  like  chairs,  etc., 
unnecessarily,  it  is  possible  to  make  a  satisfactory  aural  dressing  in 
the  treatment  room  of  the  surgeon. 

The  author  always  prefers  to  begin  the  after-treatment  following 
an  incision  of  the  drum  membrane  by  the  insertion  of  a  sterile  gauze 
wick  to  the  bottom  of  the  auditory  canal,  and  so  placing  the  innermost 
end  of  such  a  strip  that  it  lies  in  direct  contact  with  the  incision  in  the 
membrane  (Fig.  146).  Folds  of  the  wick  are  then  placed  loosely  over 
each  other  until  the  whole  auditory 
meatus  is  full  and  a  few  coils  are 
left  lying  loosely  in  the  concha. 
Under  no  circumstances  is  it  per- 
missible to  pack  the  auditory 
meatus  tightly  with  the  gauze,  but 
the  surgeon  must  always  be  sure 
that  he  has  inserted  the  distal  end 
of  the  wick  deeply  enough  to  lie 
in  actual  contact  with  the  drum 
membrane,  since  otherwise  the 
gauze  will  not  serve  the  desired 
purpose  of  capillary  suction  of  the 
exudate  from  the  tympanic  cavity, 
but  would,  on  the  contrary,  act 
rather  as  an  obstruction  to  the 
exit  of  the  secretion,  even  after  it 
has  exuded  into  the  external  auditory  canal  (Fig.  147).  When  the 
discharge  is  profuse,  such  a  gauze  wick  is  frequently  saturated  with  the 
secretion  in  a  very  short  time.  It  is  essential,  however,  to  the  carrying 
out  of  the  antiseptic  technic  that  no  one  but  the  surgeon  or  his  trained 
assistant  should  remove  this  gauze  and  reinsert  another.  The  wisest 
plan  is,  therefore,  to  provide  a  thick  pad  of  gauze  which  is  placed  over 
the  outer  ear  and  bound  to  it  with  a  roller  bandage,  to  take  up  the 
discharge  as  fast  as  it  may  appear  at  the  outer  end  of  the  gauze  wick, 
since  in  this  way  only  can  the  infection  of  the  wick  itself  be  provided 
against  and  the  necessity  of  frequent  change  of  the  dressing  be  obviated. 


FIG.  146. — METHOD  OF  DRY  PACKING  IN  THE 
TREATMENT  OF  SUPPURATIVE  MIDDLE-EAR  AFFEC- 
TIONS. 

The  distal  end  of  the  gauze  strip  lies  hi  direct 
contact  with  the  perforation  in  the  membrana  tym- 
pani,  in  which  position  it  absorbs  the  pus  as  rapidly 
as  formed. 


260  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

Hence,  at  the  first  and  at  each  subsequent  dressing,  which  is  at  the  outset 
made  daily,  after  the  insertion  of  the  wick  into  the  auditory  canal  as 
above  directed,  a  quantity  of  loose  sterile  gauze  as  large  as  can  be 
conveniently  accommodated  in  the  closed  hand  is  placed  over  the  external 
ear  and  held  in  place  by  a  roller  bandage  (Fig.  255).  At  each  daily 
dressing  of  the  ear  the  nose  and  nasopharynx  should  be  given  such 
treatment  as  may  be  indicated  by  any  local  congestion  or  inflammation 
that  is  present  in  these  localities. 

Until  convalescence  is  well  established  the  patient  is  safer  and  will 
make  more  rapid  improvement  if  he  remains  indoors,  or  if  while  feverish 
and  in  pain  he  keeps  his  bed.  The  diet  should  be  limited  and  of  such 
character  and  quantity  as  would  be  indicated  during  the  continuance 


Space  between  drum-head 
and  gauze  strip 


FIG.  147. — FAULTY  METHOD  OF  DRY  PACKING  THE  EAR. 

Note  that  the  gauze  strip  only  partially  fills  the  external  auditory  meatus,  and  that  pus  can  collect  in  the 
space  between  the  gauze  and  membrana  tympani.  Compare  the  position  of  the  distal  end  of  the  gauze  strip 
in  this  illustration  with  that  in  Fig.  146,  in  which  the  gauze  is  properly  placed. 

of  any  inflammation.  The  presence  of  constipation  must  be  remedied 
by  the  administration  of  salines,  but  if  the  patient  is  anemic  and  con- 
siderable prostration  is  present,  the  extract  of  cascara  sagrada  is  prefer- 
able as  a  laxative.  In  this  class  of  cases  ferruginous  tonics  are  also 
most  helpful  when  given  in  connection  with  the  local  treatment. 

After  a  persistence  in  the  above  treatment  for  four  or  five  days  by 
means  of  the  gauze  wick,  if  the  aural  discharge  shows  no  indication  of 
lessening,  or  if  it  should  become  more  profuse  and  purulent  in  character, 
it  may  be  deemed  wise  to  abandon  this  method  and  to  substitute  therefor 
the  plan  of  syringing  the  ear.  The  frequency  with  which  a  discharging 
ear  should  be  syringed  depends  upon  the  amount  of  the  secretion, 
which,  when  very  free,  may  require  cleansing  every  two  or  three  hours, 
whereas,  only  once  or  twice  a  day  may  suffice  if  the  discharge  is  scanty. 


ACUTE   CATARRHAL   OTITIS    MEDIA  261 

When  the  discharge  has  lessened  to  the  degree  that  it  no  longer  appears 
at  the  external  orifice  of  the  auditory  meatus,  the  syringing  should  be 
withheld  entirely,  since  persistence  in  its  use  after  that  time  will  often 
favor  an  exacerbation  of  the  inflammation  within  the  middle  ear.  When 
quite  scanty,  therefore,  the  discharge  is  best  managed  by  wiping  it  away 
with  a  small  pledget  of  cotton  wound  upon  the  end  of  the  aural  applicator, 
after  which  the  meatal  walls,  and  especially  the  outer  or  hair-growing 
parts  of  the  external  auditory  meatus,  should  be  sterilized  by  rubbing 
them  with  the  boric  acid  and  alcohol  solution.  Folio  wing 'any  of  the 
methods  of  cleansing  the  ear  the  whole  auditory  canal  should  be  finally 
left  dry,  and  as  a  finishing  dressing  a  small  quantity  of  powdered  boric 
acid  or  boric  acid  mixed  with  zinc  oxid  should  be  blown  into  the 
canal  and  a  thin  coating  everywhere  deposited  upon  its  walls  and  upon 
the  dermoid  surface  of  the  drum  membrane.  The  mistake  must  not 
be  made  of  insufflating  a  large  quantity  of  any  kind  of  powder  into  an 
ear  that  is  discharging,  for  the  reason  that  the  powder  blocks  the  incision 
or  perforation  in  the  membrana  tympani,  and  thus  hinders  rather  than 
facilitates  the  drainage  from  the  middle  ear. 

When  the  case  is  not  seen  by  the  surgeon  until  spontaneous  perfora- 
tion of  the  drum  membrane  has  already  taken  place,  and  the  opening 
through  the  tympanic  membrane  is  seen  to  be  ample  to  provide  free 
drainage,  the  same  methods  of  treatment  may  be  instituted  that  have 
here  been  advocated  as  proper  subsequent  to  an  incision.  But  if  the 
perforation  is  found  to  be  small  and  the  patient  continues  to  suffer 
almost  if  not  quite  as  much  as  before  the  rupture  took  place,  then  the 
opening  should  be  enlarged  by  a  free  incision  with  the  knife,  exactly 
as  if  no  perforation  had  ever  occurred.  It  sometimes  happens  that  even 
after  a  very  free  incision  of  the  membrane  that  union  of  the  lips  of  the 
wound  takes  place  before  the  discharge  subsides,  in  which  case  the  good 
effects  of  the  paracentesis  which  occurred  immediately  afterward  are 
followed  by  a  recurrence  of  the  former  pain  and  other  symptoms  which 
characterized  the  onset  of  the  original  attack  of  the  catarrhal  otitis 
media.  Under  such  circumstances  a  second  and  equally  free  incision 
of  the  drum-head  should  be  made. 

During  the  height  of  the  inflammation  it  is  not  wise  to  inflate  the 
middle  ear  by  any  method.  To  do  so  usually  increases  the  pain  already 
present  or  causes  a  recurrence  of  that  which  is  subsiding.  As  the  acute 
inflammation  abates,  however,  and  when  the  pain  and  other  accompany- 
ing symptoms  of  the  acute  catarrhal  otitis  have  in  great  measure  dis- 
appeared, inflation  is  to  be  advocated,  and  if  the  air  is  carefully  injected 
through  the  catheter  or  by  means  of  the  Politzer  bag  the  restoration  of 


262  THE    PRINCIPLES   AND    PRACTICE    OF   OTOLOGY 

the  inflamed  middle-ear  tissues  to  the  normal  is  thereby  hastened. 
During  the  course  of  this  disease  when  left  entirely  to  nature,  the  drum 
membrane  is  forced  into  an  abnormal  position,  in  which  case  the  tym- 
panic membrane  is  retracted  or  it  may  be  bulged  outward  by  the 
accumulations  of  exudate  within  the  tympanic  cavity.  The  tendency 
is  often  toward  the  retention  in  the  cavum  tympani,  even  after  the  most 
thorough  paracentesis,  of  a  portion  of  the  exudate,  which  may  ultimately 
organize  and  bind  both  drum  membrane  and  ossicles  into  either  of  the 
above  abnormal  situations.  The  best  means  of  avoiding  this  occurrence 
is  the  early  and  complete  evacuation  of  the  tympanic  exudate  as  already 
stated,  and  then  following  this  by  the  immediate  replacement  of  the 
membrana  by  means  of  the  air  douche,  or  inflation  by  means  of  the 
Eustachian  catheter.  The  employment  of  the  catheter  is  usually 
preferable  in  adults  provided  skill  is  used  during  its  introduction,  for 
the  reason  that  the  amount  of  force  with  which  the  air  is  caused  to  enter 
the  tympanic  cavity  can  by  this  means  be  regulated  more  accurately, 
and  moreover  since  very  often  only  one  ear  is  affected,  it  is  undesirable 
to  inflate  both,  as  would  happen  when  the  Politzer  method  is  employed. 
At  first  the  inflation  should  be  performed  daily,  but  as  the  hearing 
distance  increases  and  the  drum  membrane  is  seen  on  examination  to 
be  regaining  its  normal  position  and  color,  the  inflation  may  be  made 
only  every  second  or  third  day,  and  finally,  only  rarely  or  not  at  all. 

In  case  the  ailment  shows  a  tendency  to  become  subacute  or  chronic, 
as  indicated  by  its  behavior  subsequently  to  the  incision  of  the  membrane, 
notably  by  undue  continuance  of  the  discharge  and  delayed  healing 
of  the  perforation,  stimulating  vapors  are  sometimes  more  helpful  than 
simple  air,  if  injected  through  the  catheter,  the  method  of  their  em- 
ployment being  exactly  similar  to  that  already  described. 

Should  the  exudate  within  the  middle  ear  become  infected  from 
without,  either  after  spontaneous  rupture  or  an  incision  of  the  drum 
membrane,  the  discharge  becomes  quickly  purulent,  tissue  necrosis  may 
take  place,  and  the  disease  finally  becomes  chronic.  The  treatment  for 
this  latter  disease  is  given  in  Chapter  XXVII.,  to  which  reference  is  now- 
made. 


CHAPTER  XXIII 
ACUTE    SUPPURATIVE   OTITIS   MEDIA 

THIS  disease  is  characterized  by  a  group  of  symptoms  that  is  more 
severe  in  every  way  than  that  which  accompanies  the  two  preceding 
varieties  of  middle-ear  affection.  The  inflammation  is  not  only  more 
violent,  but  the  resulting  destruction  of  tissue  within  the  middle  ear  is 
correspondingly  greater,  and  therefore  the  permanent  impairment  of 
function  is  also  greater.  It  is  chiefly  because  of  the  extensive  damage 
resulting  from  tissue  necrosis  of  the  middle  ear  during  the  progress  of 
this  disease  that  it  is  regarded  by  otologists  as  the  most  serious  of  all 
the  acute  aural  affections.  Chronic  suppurative  otitis  media  follows 
the  acute  variety  in  a  very  considerable  proportion  of  cases,  and  espe- 
cially in  those  in  which  treatment  has  been  neglected. 

Causation. — All  the  causes  that  were  enumerated  in  the  chapters 
on  Acute  Catarrhal  Otitis  Media  and  Acute  Tubotympanic  Congestion 
are  also  among  the  etiologic  factors  productive  of  the  acute  suppurative 
form.  The  chief  difference  between  the  two  former  diseases  and  the 
one  under  consideration  lies  in  the  violence  of  the  causative  disease. 
Thus  a  mild  attack  of  nasopharyngitis,  tonsillitis,  or  measles  may  be 
productive  of  nothing  more  than  a  tubotympanic  catarrh,  whereas 
in  the  same  individual,  if  the  pathogenic  bacteria  which  are  causative 
of  the  primary  disease  are  of  a  more  virulent  nature,  any  secondary 
affection  of  the  middle  ear  will  usually  be  of  a  catarrhal  or  suppurative 
variety.  Hence  otitis  media  suppurativa  is  comparatively  rare  as  a 
complication  of  the  mild  inflammatory  affections  of  the  throat  or  of  the 
mild  varieties  of  the  acute  infectious  diseases,  whereas  it  is  quite  common 
as  a  sequence  of  these  affections  when  occurring  in  a  severe  form. 

Of  the  general  diseases  which  most  frequently  cause  suppuration 
of  the  tympanic  cavity,  those  of  a  specific  infectious  character  stand 
first.  The  affections  of  this  class  which  are  most  clearly  responsible 
for  the  aural  complications  are,  in  the  order  of  frequency  in  which  the 
tympanic  suppuration  results,  scarlatina,  measles,  epidemic  influenza, 
and  diphtheria.  The  disastrous  effects  of  these  diseases  upon  the 
organ  of  hearing  are  so  frequently  witnessed  and  occupy  such  an  impor- 
tant place  in  otology  that  a  complete  discussion  of  each  in  its  causa- 

263 


264  THE    PRINCIPLES    AND   PRACTICE   OF   OTOLOGY 

live  relation  to  aural  diseases  becomes  essential  to  the  student  of  this 
subject. 

Scarlatina  is  probably  the  greatest  enemy  of  the  ear.  In  the  worst 
forms  of  this  disease,  occurring  during  certain  epidemics,  and  in  damp, 
cold  weather,  the  tympanic  cavity  is  involved  in  an  inflammatory  or 
suppurative  process  in  as  many  as  one-third  of  all  cases,  and  is  the  most 
frequent  complication  of  scarlatina.  Both  the  severity  and  frequency 
of  the  aural  complication  of  scarlatina  depends  upon  the  character  of 
the  angina  which  accompanies  the  general  disease.  Thus,  if  the  throat 
involvement  which  accompanies  the  exanthem  is  of  only  an  erythematous 
type  the  ear  is  seldom  implicated,  and  should  extension  to  the  tympanic 
cavity  take  place,  its  character  is  more  apt  to  be  catarrhal  than  suppura- 
tive. When,  however,  the  angina  which  accompanies  the  scarlatina 
is  more  intense  or  is  of  the  membranous  variety,  a  suppurative  otitis 
media  is  an  almost  constant  complication,  is  of  a  violent  nature,  and 
mastoid  extension  is  frequently  met  with.  The  direct  and  exciting  cause 
of  the  aural  suppuration  in  scarlet  fever  is  the  presence  in  the  pharynx 
and  nasopharynx  of  large  numbers  of  pathogenic  bacteria,  in  the 
worst  cases,  chiefly  of  the  streptococcus,  which  finds  its  way  directly 
into  the  tympanum  through  the  Eustachian  tube.  This  migration  of 
the  infective  bacteria  is  favored  in  the  case  of  infants  and  young  children 
by  the  fact  that  in  early  life  the  Eustachian  tube  is  shorter  and  more 
patent  than  in  the  adult,  whereas  in  the  latter  the  bacteria  are  often 
driven  through  the  Eustachian  tube  by  the  powerful  efforts  the  patient 
makes  in  blowing  his  partially  or  perhaps  wholly  occluded  nose. 

Measles,  next  to  scarlet  fever,  must  be  regarded  as  the  most  frequent 
cause  of  acute  otitis  media.  Both  Tobietz  and  Bezold  have  ascer- 
tained by  the  collective  post-mortem  examination  of  38  cases  of  death 
resulting  from  measles,  during  the  early  stages,  that  the  inflammation 
had  traveled  to  the  tympanum  and  that  there  was  already  present  in 
this  cavity  a  mucopurulent  or  purulent  exudate.  In  the  early  stage  of 
measles  the  tympanic  involvement  is  due,  therefore,  to  the  presence 
of  the  inflammation  which  is  characteristic  of  this  exanthem,  and  not 
to  a  secondary  infection  which  results  from  the  migration  of  pathogenic 
bacteria  from  the  rhinopharynx.  Later  in  the  disease,  however,  strep- 
tococci and  staphylococci,  which  are  present  in  the  nasopharyngeal 
space,  find  their  way  into  the  cavum  tympani,  and  an  active  suppuration 
is  quickly  developed  as  a  result. 

Diphtheria  causes  a  suppurative  otitis  media,  in  many  instances  at 
least,  by  an  active  extension  of  the  diphtheritic  membrane  from  the 
vault  of  the  pharynx,  through  the  Eustachian  tube  into  the  middle  ear. 


ACUTE    SUPPURATIVE    OTITIS    MEDIA  265 

After  the  rupture  of  the  drum  membrane  has  occurred  a  bacteriologic 
examination  of  the  aural  discharge  shows  the  presence  of  the  bacillus 
of  diphtheria  associated  with  streptococci  and  staphylococci.  Paralysis 
of  the  palatal  muscles  frequently  occurs  either  during  the  progress  of 
the  diphtheria  or  as  a  sequel,  and  the  impairment  of  function  resulting 
to  the  muscles  which  act  to  open  the  Eustachian  tube  often  produces  a 
greater  or  less  degree  of  deafness,  and  this  temporary  loss  of  muscular 
function  no  doubt  furnishes  a  predisposing  cause  of  the  spread  of  the 
membrane  to  the  tympanic  cavity  with  resulting  suppuration. 

Epidemic  influenza,  as  is  now  well  known,  exists  in  two  well-defined 
types :  that  which  affects  principally  the  nervous  system  and  that  which 
involves  chiefly  the  mucous  membrane.  The  latter  variety  of  la  grippe 
is  almost  wholly  responsible  for  middle-ear  inflammation  in  so  far  as  the 
latter  is  due  to  the  former  disease.  In  the  catarrhal  variety  of  la  grippe 
the  mucous  membrane  of  the  nose,  pharynx,  and  nasopharynx  becomes 
intensely  inflamed,  and  from  these  central  spaces  the  inflammatory 
process  frequently  spreads  to  one  or  more  adjoining  sinuses,  as,  for 
example,  to  the  antrum  of  Highmore  through  the  ostium  maxillaire 
or  to  the  tympanic  cavity  by  way  of  the  Eustachian  tube.  It  has  not 
as  yet  been  determined  whether  or  not  the  influenza  bacillus  is  the  sole 
cause  of  the  inflammation  of  the  upper  respiratory  tract,  and  of  the 
accompanying  suppuration  \vhich  so  frequently  occurs  in  the  middle 
ear  or  one  of  the  accessory  sinuses  of  the  nose.  In  the  severe  forms  of 
otitis  media  due  to  la  grippe,  streptococci,  staphylococci,  and  pnuemococci 
are  frequently  found  in  the  discharge  from  the  ear.  These  bacilli  have 
no  doubt  found  entrance  into  the  tympanum  in  an  exactly  similar  manner 
to  that  already  described  in  scarlet  fever  and  measles,  and  have,  as  in 
those  diseases,  furnished  the  exciting  cause  of  the  otitis. 

The  presence  of  adenoids  and  enlarged  tonsils  in  any  individual 
who  is  attacked  by  one  of  the  above  infectious  or  contagious  diseases 
adds  greatly  to  the  probability  of  an  extension  of  the  inflammatory 
process  to  the  middle  ear  (see  Chapter  XX.,  p.  203). 

An  acute  suppurative  otitis  media  may  be  secondary  to  a  trau- 
matic injury  to  the  drum  membrane,  following  which  an  infection 
of  the  tympanic  cavity  takes  place  from  the  external  auditory  meatus, 
through  the  perforation.  A  tubotympanic  catarrh  in  which  spon- 
taneous rupture  of  the  drum  membrane  has  taken  place,  or  in  which 
a  paracentesis  of  the  drum  membrane  has  been  made,  may  be  fol- 
lowed by  secondary  infection  of  the  tympanic  cavity,  and  a  purulent 
inflammation  be  thereby  established  in  this  cavity  which  was  previously 
so  mildly  infected  as  to  be  comparatively  but  little  diseased.  Following 


266  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

a  spontaneous  rupture  or  an  incision  of  the  drum  membrane  in  any 
case  of  non-infected  middle-ear  disease,  a  careless  or  indifferent  mode 
of  after-treatment  on  the  part  of  the  physician  may  quickly  lead  to 
infection  of  the  drum  cavity  and  to  the  establishment  of  the  acute 
suppurative  variety  of  the  disease. 

The  most  potent  predisposing  factor  in  the  causation  of  this,  as  of 
the  other  acute  middle-ear  affections,  is  an  inflamed  nasopharynx  or 
one  that  is  occluded  by  growths,  notably  adenoids.  The  presence  of 
this  hypertrophy  is  productive  of  a  retarded  venous  circulation  of  the 
Eustachian  tube  and  middle  ear,  and  of  the  secretion  of  a  large  amount 
of  pathologic  mucus.  Nasopharyngeal  obstruction  furnishes  both 
an  ideal  location  and  the  most  favorable  conditions  for  the  harboring 
and  culture  of  these  pathogenic  micro-organisms  which  determine  the 
character  and  severity  of  the  different  forms  of  inflammation  which  may 
occur  within  the  middle  ear. 

Pathology. — The  mucous  membrane  of  the  middle  ear  is  more  or 
less  swollen,  the  subepithelial  layer  contains  serous  and  round-cell 
infiltration,  with  more  or  less  hemorrhage  into  the  tissue.  The  infiltra- 
tion spreads,  according  to  the  intensity  and  extent  of  the  process,  to  the 
promontory,  tegmen,  and  membrana  tympani.  The  mucous  membrane 
is  bathed  in  pus  or  blood  and  pus  mixed  with  bacteria.  The  process 
may  involve  the  whole  middle  ear  or  only  parts.  By  softening  through 
necrosis,  according  to  the  intensity  of  the  inflammation,  the  drum 
membrane  gives  way  (see  chapter  on  Bacteriology). 

Symptoms. — The  early  symptoms  of  acute  suppurative  otitis  media 
are  much  the  same  as  in  the  catarfhal  variety,  the  chief  difference  being 
the  greater  severity  of  those  attending  the  suppurative  disease.  Thus, 
the  pain  is  more  severe  and  tearing,  the  temperature  is  higher,  and  the 
prostration  of  the  patient  is  greater  in  the  latter  form.  The  temperature 
is  nearly  always  slightly  elevated,  and  may  reach  102°,  103°,  or  even 
104°  F.,  and  the  pulse  is  correspondingly  increased.  After  a  continu- 
ance of  the  pain  and  fever  for  from  one  to  three  days  the  drum  membrane 
ruptures  and  a  yellowish  discharge  appears  in  the  external  auditory 
meatus.  After  the  perforation  takes  place  the  pain  completely  subsides 
or  is  greatly  modified,  the  patient  sinks  into  the  first  sleep  he  has  been 
permitted  to  enjoy  since  the  onset  of  the  pain,  and  both  he  and  his 
friends  are  apt  to  believe  that  speedy  recovery  is  assured.  However, 
if  the  perforation  is  inadequate  to  provide  perfect  drainage  or  if  it  is 
badly  located  for  this  purpose,  the  pain  very  quickly  returns  and  the 
suffering  becomes  almost  if  not  quite  as  great  as  before.  Tinnitus  au- 
rium  and  vertigo  are  usually  present,  but  the  intensity  of  the  pain  so 


ACUTE   SUPPURATIVE    OTITIS    MEDIA  267 

obscures  these  symptoms  that  the  individual  makes  no  complaint  in  this 
respect  until  the  pain  has  disappeared  and  the  convalescent  stage  is 
entered  upon;  or  in  some  cases  not  until  the  disease  has  become  sub- 
acute  or  chronic. 

When  an  acute  suppurative  otitis  media  results  from  an  infective 
scarlatinal  angina,  it  may  come  on  at  any  time  during  the  course  of  the 
disease,  as  early  as  the  fifth  day  and  as  late  as  the  thirty-fifth,  from  the 
onset  of  the  scarlet  fever.  The  most  frequent  period  of  the  occurrence 
of  the  aural  complication  is  the  eighth  to  the  tenth  day  of  the  primary 
disease.  Either  one  or  both  ears  may  be  involved,  but  if  both  are 
affected  in  the  same  case,  usually  an  interval  of  from  one  to  several 
days  intervenes  between  the  appearance  of  the  discharge. 

The  symptoms  of  otitis  media  when  occurring  as  a  complication  of 
scarlatina  vary  somewhat  according  to  the  stage  of  the  general  disease 
in  which  the  otitis  commences,  and  upon  the  severity  of  the  fever  and 
other  symptoms  present  in  the  primary  affection  at  the  time.  Thus, 
if  the  otitis  occurs  early,  and  therefore  when  the  fever  is  high  and  the 
prostration  of  the  patient  very  great,  the  symptoms  denoting  the  onset 
of  the  aural  complication  may  be  so  masked  as  to  be  completely  over- 
looked until  the  discharge  makes  its  appearance  at  the  auditory  meatus. 
Masking  of  the  symptoms  of  otitis  in  infants  and  young  children  is 
common,  and  unless  objective  means  of  diagnosing  the  presence  of  the 
complication  are  frequently  employed  during  the  progress  of  the  scarlet 
fever,  the  presence  of  the  otitis  will  usually  be  entirely  unrecognized  at 
a  period  sufficiently  early  to  enable  the  attending  surgeon  to  institute  the 
most  effective  treatment.  Should  the  otitis  occur  during  convalescence 
from  the  scarlet  fever,  and  after  the  temperature  has  perhaps  for  several 
days  been  normal,  the  temperature  will  again  suddenly  rise  and  severe 
pain  in  the  ear  will  be  complained  of  by  the  patient.  Immediately 
after  rupture  of  the  drum  membrane  or  after  a  free  incision  has  been 
made  and  the  pent-up  exudate  of  the  tympanic  cavity  is  set  free,  both 
the  pain  and  fever  usually  subside. 

Occurring  as  a  complication  of  measles  the  otitis  may  develop  early 
or  late.  When  it  appears  early,  and  especially  in  the  milder  cases  of 
measles,  the  tympanic  complication  is  usually  a  catarrhal  and  not  a 
suppurative  otitis  media,  and  is  at  this  stage  the  result  of  the  extension  of 
the  characteristic  inflammation  of  measles  from  the  throat  to  the  middle 
ear.  When,  however,  the  tympanic  complication  occurs  after  the 
first  week  of  the  measles,  it  is  then  due  to  astreptococcicorstaphylococcic 
infection  of  the  middle  ear,  and  suppuration,  rupture  of  the  drum-head, 
and  subsequent  aural  discharge  are  the  inevitable  results. 


268  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

The  discharge  is  usually  profuse  at  first,  and  in  those  severe  cases 
where  the  destruction  of  tissue  has  been  considerable  it  may  continue 
so  for  many  days,  weeks,  or  even  indefinitely.  It  is  not  offensive  in 
odor  and  does  not  become  so  unless  there  is  retention  in  some  portion 
of  the  suppurating  tract,  or  in  the  external  auditory  meatus  after  it  has 
been  discharged  through  the  perforated  membrane.  In  some  instances 
the  amount  of  the  discharge  is  so  great  that  it  is  at  once  recognized  as 
impossible  that  all  of  it  could  be  formed  in  so  small  a  cavity  as  the 
middle  ear  alone.  Politzer  has  stated  that  suppuration  of  the  tympanic 
cavity  is  frequently  accompanied  by  the  presence  of  pus  in  the  mastoid 
antrum,  even  when  no  symptom  whatever  of  mastoiditis  is  present. 
Hence,  it  is  always  probable  in  cases  of  very  profuse  aural  discharge 
that  a  portion  of  the  pus  is  furnished  by  the  cavity  of  the  mastoid. 

In  case  the  mastoid  antrum  is  involved  and  the  drainage  from  it  is 
poor,  or  in  case  the  mastoid  cells  are  infected  and  filled  with  suppurative 
products,  and  perfect  drainage  is  therefore  a  physical  impossibility, 
pain  speedily  develops  in  the  mastoid  region  as  the  result  of  pus  retention 
and  subsequent  intramastoid  pressure.  The  onset  of  a  complicating 
mastoiditis  is,  therefore,  usually  indicated  by  pain  behind  the  ear,  worse 
at  night,  and  increased  by  pressure  over  certain  areas  of  most  frequent 
mastoid  tenderness  (see  p.  281,  Fig.  151).  Any  of  the  intracranial 
complications  may  follow  an  acute  suppurative  otitis  media,  and  the 
possibility  of  such  an  occurrence  should  always  be  borne  in  mind, 
because  the  early  symptoms  of  brain,  meningeal,  or  sinus  involve- 
ment are  often  obscure  unless  studied  from  day  to  day  in  their 
minutest  detail.  (For  symptoms  of  Intracranial  Complications  see 
Chaps.  XXXI.-XXXV.) 

When  acute  suppurative  otitis  media  results  from  a  tuberculous  de- 
posit in  the  middle  ear  the  disease  runs  its  course  up  to  the  period  of 
perforation  of  the  tympanic  membrane  and  subsequent  discharge, 
without  the  development  of  any  symptoms  pointing  to  an  aural  affection. 
But  little  or  no  pain  precedes  the  rupture  of  the  membrana  and  no 
change  in  the  temperature  precedes  or  accompanies  it.  On  the  other 
hand,  when  occurring  as  a  complication  of  a  zymotic  or  other  disease, 
the  pain  in  the  ear  is  intense,  the  temperature  rises  several  degrees,  and 
frequently  symptoms  of  meningitis  are  developed.  Enlargement 
of  the  cervical  lymphatics  is  a  symptom  of  some  cases  of  acute  sup- 
purative otitis  media,  in  which  case  the  neck  is  stiff  and  painful  upon  pres- 
sure or  when  the  patient  moves  or  turns  the  head.  If  the  whole  chain  of 
glands  is  infected  and  swollen  the  disease  might  be  mistaken  for  the 
"sausage-like  infiltration,"  which  is  said  to  accompany  thrombosis  of 


ACUTE    SUPPURATIVE   OTITIS    MEDIA  269 

the  lateral  sinus  and  jugular  vein,  whereas  if  only  the  uppermost  glands 
of  the  cervical  chain  are  involved,  the  condition  may  somewhat  resemble 
mumps. 

The  appearance  of  the  drum  membrane  as  seen  by  reflected  light 
is  not  characteristic  of  this  disease,  for  the  infiltration  and  inflammatory 
discoloration  and  bulging  may  very  closely  resemble  that  which  occurs 
during  the  acute  catarrhal  otitis  or  even  a  myringitis,  in  which  latter 
the  tympanic  cavity  is  only  rarely  involved  in  the  inflammatory  process. 
However,  the  inflammation  of  the  drum-head  during  an  acute  suppura- 
tive  otitis  media  is  oftenest  seen  to  be  more  intense  over  ShrapnelTs 
membrane  and  over  the  upper  portion  of  the  membrana  vibrans  than 
is  the  case  in  the  other  diseases  just  mentioned;  and  moreover  in  the 
latter  disease  the  subsequent  bulging  of  the  parts  from  the  pressure  of 
the  intratympanic  exudate  most  often  takes  place  in  the  upper  quadrants 
of  the  membrana  tympani.  The  membrane  is  always  intensely  and 
uniformly  reddened,  the  landmarks  are  all  obliterated  with  the  possible 
exception  of  the  short  process,  and  in  from  twenty-four  to  forty-eight 
hours  from  the  onset  more  or  less  bulging  can  usually  be  made  out. 
Within  from  one  to  several  days  the  pressure  of  the  intratympanic  fluid 
stretches  the  membrana  at  some  point,  weakens 
or  impairs  the  circulation  over  some  area,  and  as 
a  result  the  membrane  is  ulcerated  and  finally 
gives  way,  allowing  the  pus  to  flow  freely  into  the 
auditory  canal.  Previous  to  the  occurrence  of 
the  rupture  the  height  of  the  bulging  area  usually 
appears  as  a  somewhat  whitened  or  yellowish 
patch  in  the  midst  of  the  intensely  reddened 

FIG.  148. — BULGING  DRUM- 
field    (Fig.    148).       After    the    rupture    the    pUS   is       HEAD   WITH   BEGINNING   NE- 

seen  filling  the  auditory  canal,  and  when  this  is  ^S™^"6*™* 
mopped  away  by  sterile  cotton  pledgets  the 

point  of  rupture  is  often  visible,  a  drop  of  pus  is  seen  filling  the 
opening,  and  this  pulsates  synchronously  with  the  heart-beat. 

The  shape  of  the  perforation  which  has  occurred  spontaneously 
is  slit-like  at  first  and  may  run  in  any  direction.  After  it  has  persisted 
for  a  time  granulation  takes  place  at  the  extremities  of  this  slit,  while 
dilatation  occurs  at  the  center,  with  the  result  that  the  opening  usually 
takes  on  a  circular  form  (see  Fig.  194).  In  those  cases  complicating  the 
infectious  diseases  in  which  the  aural  affection  is  violent,  the  greater 
portion  of  the  membrana  vibrans  is  sometimes  quickly  destroyed,  leaving 
only  a  narrow  margin  at  the  annulus  tympanicus.  Should  this  have 
happened  the  inner  tympanic  wall  will  be  seen  through  the  large  opening, 


270          THE  PRINCIPLES  AND  PRACTICE  OF  OTOLOGY 

but  on  account  of  the  infiltrated  and  inflamed  condition  of  the  tympanic 
mucous  membrane  it  may  be  mistaken  for  the  drum  membrane  itself, 
and  the  true  condition  of  the  latter  may  therefore  pass  unrecognized. 
At  the  same  time  the  membrana  tympani  is  destroyed  the  ossicles,  and 
especially  the  incus,  may  also  suffer  necrosis  and  be  swept  away  together 
with  other  necrotic  middle-ear  structures.  The  handle  of  the  malleus 
may  still  be  recognized  in  its  usual  position,  projecting  like  a  peninsula 
downward  and  backward  to  the  center  of  the  field  (see  Fig.  191). 

A  small  perforation  always  heals  rapidly  in  otherwise  healthy  indi- 
viduals, and  will  usually  close  permanently  just  as  soon  as  the  formation 
and  discharge  of  pus  has  ceased.  Indeed,  in  many  instances  the  tendency 
of  the  opening  is  to  close  too  rapidly,  thereby  blocking  the  discharge 
and  bringing  about  the  necessity  for  subsequent  enlargement  by  a  second 
incision.  During  the  healing  of  the  larger  perforation,  exuberant 
granulations  often  spring  from  the  edges  of  the  rupture,  from  a  necrotic 
ossicle,  or  from  a  carious  spot  on  some  portion  of  one  of  the  tympanic 
walls;  and  these  when  present  can  be  seen,  or  at  least  felt,  with  the 
probe  during  the  physical  examination  of  the  condition  of  the  drum 
membrane.  As  the  inflammation  in  the  middle  ear  subsides  and  the 
perforation  in  the  membrane  heals,  the  inflammatory  redness  and 
thickness  of  the  tympanic  membrane  are  likewise  seen  to  subside  from 
day  to  day;  and  as  the  normal  color  and  texture  return,  the  landmarks 
reappear — first  the  short  process  of  the  malleus,  then  the  manubrium, 
umbo,  color,  and  light  reflex,  in  the  order  mentioned.  When  the  in- 
flammation has  almost  disappeared,  radiating  injected  vessels  are  some- 
times seen  coursing  over  the  membrane.  The  very  large  openings 
which  result  from  the  loss  of  the  greater  portion  of  the  drumhead 
remain  permanently  (see  Fig.  197). 

Diagnosis. — The  diagnosis  will  usually  not  be  difficult  if  the  physi- 
cian takes  into  account  the  history  and  symptoms  of  the  case,  the  presence 
of  an  infection  in  the  throat,  or  the  coexistence  of  some  one  of  the 
zymotic  diseases  in  connection  with  the  information  he  is  able  to  obtain 
by  an  exacting  physical  examination  of  the  drum  membrane  and  middle 
ear.  This  affection  is  likely  to  be  mistaken  only  for  a  myringitis,  for 
acute  catarrhal  otitis  media,  or  for  a  furunculosis  of  the  external  auditory 
canal.  The  differential  diagnosis  of  these  affections  is  given  more 
concisely  on  p.  277,  to  which  the  reader  is  referred. 

Early  diagnosis  of  the  tympanic  complication  of  the  specific  infec- 
tious diseases  is  of  the  first  importance  for  the  reason  that  the  best 
results  from  treatment  of  the  same  are  only  possible  when  such  treatment 
is  instituted  at  the  very  onset  of  the  aural  disease.  It  should  be  the  rule, 


ACUTE    SUPPURATIVE   OTITIS    MEDIA  271 

therefore,  in  any  case  of  scarlet  fever,  measles,  la  grippe,  or  diphtheria 
to  inspect  the  tympanic  membrane  of  the  patient  from  day  to  day; 
for,  as  has  already  been  stated,  aural  complication  in  all  these  diseases 
is  frequent,  and  the  severity  of  the  constitutional  disease  frequently 
so  completely  masks  the  tympanic  complication  that  the  latter  will  often 
pass  unrecognized  unless  the  drum  membrane  is  inspected  daily  by 
means  of  reflected  light.  Such  an  inspection  in  children  is  not  always 
easy,  and  the  interpretation  of  the  appearances  of  the  drum  membrane 
is  likely  to  be  erroneous  unless  the  patient  is  properly  placed  or  held  in 
position  for  such  an  examination,  unless  a  good  source  of  light  is  pro- 
vided, and  unless  the  examiner  remembers  that  in  an  examination  of 
the  drum-head  in  the  case  of  infants  and  the  very  young  he  must  pull 
the  auricle  downward  and  backward,  and  not  upward  and  backward, 
as  should  be  the  rule  in  adults  (see  Fig.  82). 

The  violence  of  the  scarlatinal  infection  upon  the  tympanic  struc- 
tures is  sometimes  both  rapid  and  extensive.  Mastoiditis  is  frequently 
the  result  of  an  extension  of  the  suppuration  into  the  mastoid  antrum 
and  mastoid  cells.  Cases  of  necrosis  of  the  labyrinth  have  been  reported 
by  Bezold,  Pye,  and  many  others.  The  necrotic  extension  of  the  disease 
within  the  temporal  bone  has,  in  a  few  instances,  implicated  the  large 
blood-vessels  in  the  immediate  vicinity  of  the  ear,  resulting  in  a  fatal 
hemorrhage.  Hays  and  Hassler  have  each  reported  a  case  in  which  the 
carotid  artery  was  eroded  with  an  ensuing  fatal  hemorrhage.  Baader 
narrates  an  instance  of  a  child  three  years  old  suffering  from  scarlatinal 
otitis,  in  which  death  occurred  from  extension  of  the  disease  into  the 
mastoid  and  with  subsequent  erosion  of  the  sigmoid  sinus.  Huber, 
Kennedy,  West,  and  Moller  have  collectively  reported  6  cases  of  fatal 
bleeding  as  a  result  of  the  necrotic  invasion  of  the  carotid  artery  or 
lateral  sinus  subsequent  to  a  scarlatinal  involvement  of  the  tympanic 
cavity. 

Prognosis. — The  termination  of  acute  suppurative  otitis  media 
depends  much  upon  the  violence  of  the  attack  and  upon  the  promptness 
and  efficiency  with  which  treatment  is  instituted.  In  those  cases  in 
which  the  onset  is  sudden  and  unusually  severe  from  the  first,  extensive 
necrosis  of  both  the  soft  and  osseous  structures  of  the  tympanic  cavity 
takes  place  so  quickly  that  it  is  often  impossible  to  successfully  combat 
the  destruction,  and  the  result  is  a  permanent  loss  of  tissue  and  a 
corresponding  loss  of  function.  When  death  takes  place  as  a  result 
of  this  disease,  it  usually  does  so  from  some  intracranial  complication 
which  is  set  up  because  of  the  transportation  of  pathogenic  bacteria 
into  the  cranial  cavity,  either  through  the  blood  or  lymph  currents  or 


272  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

as  the  result  of  necrosis  of  the  bone  in  the  direction  of  the  brain,  and 
the  direct  admission  of  the  septic  fluid  into  the  skull  cavity.  Such  a 
complication  may  arise  during  the  acute  stage  of  the  aural  suppuration 
or  it  may  occur  at  any  subsequent  period  of  the  patient's  life,  should 
the  acute  disease  become  chronic. 

The  milder  and  more  common  forms  of  the  affection,  if  permitted 
to  continue  untreated,  will  terminate  differently,  the  difference  depending 
greatly  upon  the  patient's  constitution,  habitation,  and  mode  of  life. 
The  tubercular  case  becomes  quickly  chronic  and  usually  incurable. 
In  the  poorly  nourished  and  badly  housed  individual  who  must  perhaps 
resume  his  occupation  in  unfavorable  weather  and  before  the  tympanic 
inflammation  is  cured,  the  disease  will  almost  inevitably  continue 
indefinitely,  and  finally  become  a  chronic  suppurative  otitis.  In  children 
whose  upper  respiratory  tract  is  obstructed  by  adenoids,  recurrence 
of  the  suppurative  inflammation  of  the  middle  ear  is  the  rule,  and  ulti- 
mately more  or  less  destruction  of  the  drum  membrane,  or  serious  and 
permanent  impairment  of  its  function,  as  weU  as  that  of  the  middle  ear, 
may  be  expected. 

Early  and  well  directed  treatment  influences  the  termination  of 
this  disease  very  greatly.  When  the  patient  is  seen  before  serious 
necrosis  of  tissue  has  occurred,  and  a  free  outlet  for  the  suppurative 
products  is  promptly  provided  and  maintained,  it  may  in  all  the  milder 
cases  be  predicted  with  confidence  that  the  inflammation  will  promptly 
subside,  the  discharge  cease,  the  perforation  heal,  and  that  the  hearing 
will  be  restored  to  normal  or  almost  normal.  In  the  very  violent  cases, 
however,  the  best  directed  and  most  vigorous  treatment,  even  at  the 
onset,  will  often  be  insufficient  to  prevent  great  loss  of  tissue  and  con- 
sequently a  much  impaired  hearing.  In  these  latter  cases  the  question 
is  often  one  of  saving  the  life  of  the  patient  as  well  as  of  preserving  the 
hearing  apparatus,  and  the  vigorous  application  of  the  known  medical 
and  surgical  principles  of  modern  otology  in  both  these  directions  has 
proven  to  be  one  of  the  modern  surgical  triumphs. 

Treatment. — Owing  to  the  rapidity  with  which  the  purulent  variety 
of  otitis  media  often  develops,  and  the  widespread  destruction  of  tissue 
that  frequently  follows,  no  time  should  be  lost  in  meeting  the  earliest 
symptoms,  combating  the  inflammation,  and  providing  efficient  drainage 
for  the  discharge.  General  depletion  through  the  administration  of 
salines,  and  local  depletion  by  means  of  leeches  about  the  ear,  are  more 
urgently  needed  here  than  in  the  catarrhal  variety.  These  measures, 
when  used  in  connection  with  heat  applied  locally  to  the  ear,  are  often 
efficient  in  alleviating  the  pain;  but  since  several  hours  may  be  required 


ACUTE    SUPPURATIVE    OTITIS    MEDIA  273 

to  affect  the  relief  by  this  means,  it  is  usually  advisable  in  the  beginning 
to  administer  a  hypodermic  injection  of  morphin  to  assist  and  prolong 
the  effect.  Owing  to  the  fact,  however,  that  under  the  continued  use 
of  morphin  great  destruction  of  tissue,  or  intracranial  complication 
may  occur  and  yet  be  unsuspected  because  of  the  apparent  comfort 
of  the  patient,  it  is  unsafe  to  repeat  the  remedy  until  the  patient  has 
been  allowed  to  recover  from  its  influence,  and  the  physician  has 
been  given  an  opportunity  to  judge  the  condition  of  the  case  when  free 
from  the  masking  effect  of  the  anodyne.  The  same  local  applications  which 
were  advocated  for  the  relief  of  pain  in  acute  catarrhal  otitis  (see  p.  256) 
may  also  be  applied  to  the  inflamed  drum  membrane  in  this  disease, 
but  are  not  often  efficient  in  relieving  the  suffering  of  the  patient. 
Abortion  of  the  disease  by  the  foregoing  procedures,  even  when  applied 
at  the  earliest  possible  moment,  is  seldom  to  be  expected,  but  modifica- 
tion of  the  severity  of  the  inflammation  and  a  certain  degree  of  relief 
from  the  suffering  is  frequently  accomplished. 

Incision  of  the  drum  membrane  is  early  indicated  in  a  majority  of 
all  cases.  When  after  the  early  employment  of  local  and  general  de- 
pletion, of  heat  and  anesthetic  medicines  to  the  membrana,  the  pain  con- 
tinues unabated  or  but  little  relieved,  this  fact  is  evidence  of  an  inflam- 
matory pressure  within  the  tympanum  which  is  due  to  engorgement  of  the 
lining  membrane,  or  to  the  pressure  of  an  exudate  that  has  already  taken 
place  within  this  cavity.  If  paracentesis  is  not  promptly  performed, 
spontaneous  rupture  will  sooner  or  later  take  place;  but  during  the 
period  of  waiting  for  a  spontaneous  rupture  the  patient's  suffering  is  not 
only  intense,  but  pressure  necrosis  of  the  tympanic  structures  is  mean- 
while taking  place,  and  the  process  if  unchecked  may  spread  to  the 
mastoid  antrum,  mastoid  cells,  or  even  to  the  intracranial  structures. 
If,  therefore,  the  symptoms  indicate  that  the  middle-ear  infection  is  of 
a  violent  nature,  and  the  aural  examination  shows  inflammation  and 
infiltration  of  the  drum  membrane,  a  free  incision  should  be  made  at 
once,  even  if  only  a  few  hours  have  elapsed  since  the  onset  of  the  disease. 
Experience  has  shown  that  early  and  free  incision  of  the  drum-head 
in  these  cases  lessens  the  duration  of  the  disease,  shortens  the  period  of 
suffering,  and  is  the  most  reliable  means  of  preventing  mastoid  or  other 
complications.1 

1  Concerning  the  relation  between  an  early  incision  of  the  drum  membrane  and  the 
closure  of  the  perforation,  Ko'rner  states  that  as  a  result  of  paracentesis  on  the  first  day 
of  the  disease,  closure  of  the  perforation  occurred  on  the  seventh  day;  on  the  second  day 
in  13  cases,  closure  occurred  on  the  ninth  day;  on  the  third  day  in  8  cases,  per- 
foration closed  on  the  fourteenth  day;  on  the  fourth  day  in  9  cases,  perforation  closed 
in  fifteen  days;  on  the  fifth  day  in  13  cases,  perforation  closed  on  the  sixteenth  day; 
18 


274  THE   PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 

The  incision  in  the  membrana  should  always  be  of  sufficient  extent 
to  give  free  vent  to  the  suppurative  products  of  the  middle  ear.  A  mere 
puncture  of  the  membrane  with  a  "  paracentesis  needle  "  (see  Fig.  142) 
is  a  procedure  too  trivial  to  merit  consideration  and  is  mentioned  merely 
that  it  may  be  condemned.  When  the  incision  is  undertaken  before 
bulging  of  the  membrane  has  occurred,  the  cut  should  be  made  by  first 
penetrating  this  structure  in  the  posterosuperior  quadrant  at  a  point 
opposite  the  short  process  of  the  hammer,  and  with  the  edge  of  the 
knife  turned  upward  the  blade  is  pushed  inward  until  the  point  pene- 
trates the  mucous  membrane  covering  the  internal  wall  of  the  tympanic 
cavity,  after  which  the  instrument  is  carried  upward  in  such  manner 
that  both  the  membrana  tympani  and  mucous  membrane  are  severed  as 
far  as  the  tympanic  ring;  and  it  is  even  better  if  the  incision  is  then  carried 
through  the  skin  of  the  adjacent  meatus  for  a  short  distance  toward  the 
concha,  as  the  knife  is  withdrawn  (see  Fig.  143,  E,  F).  When  per- 
formed thus  early  a  discharge  of  pus  should  not  be  expected  to  follow 
immediately,  for  the  reason  that  it  has  not  yet  formed;  but  a  free 
hemorrhage  should  be  secured  as  a  result  of  the 
incision,  and  this  is  of  benefit  for  the  reason  that 
the  engorged  blood-vessels  are  thereby  unloaded, 
the  swelling  of  the  mucous  membrane  is  reduced, 
and  the  previous  acute  pain  is  greatly  relieved 
because  of  the  lessened  tension  within  the  blood- 
vessels. 

Should  the  patient  be  seen  at  a  later  period, 

FIG.    149.— SHOWING    LINE          -  ,  ,          ,  1^1-^1  •  i  n 

OF  INCISION.  after  pus  has  already  accumulated  in  the  middle- 

ear  cavity,  and  when  bulging  of  some  portion  of 
the  drum  membrane  is  apparent  on  examination  (see  Fig.  148),  the 
incision  is  made  so  as  to  include  the  summit  of  the  bulging,  and  is  then 
extended  to  the  lowermost  portion  of  the  tympanic  cavity  (Fig.  149). 

The  treatment  subsequent  to  the  incision  depends  somewhat  upon 
the  stage  of  the  disease  at  which  the  opening  is  made.  Following  an 
incision  during  the  first  few  hours  of  the  inflammation,  when  no  pus 
is  yet  present,  and  when  depletion  has  been  the  primary  object,  it  is  not 
proper  to  irrigate  the  canal  with  any  sort  of  solution;  for  if  the  external 
auditory  canal  had  been  properly  sterilized  before  the  paracentesis  was 
made,  better  results  will  follow  the  insertion  of  a  sterile  gauze  wick  to 
the  bottom  of  the  canal  (Fig.  146),  and  then  applying  the  roller  bandage 

when  paracentesis  was  done  on  the  sixth  day  in  4  cases,  healing  of  drum  membrane 
took  place  on  the  twenty-fourth  day;  when  the  incision  was  performed  on  the  seventh  day 
the  average  time  of  closure  in  20  cases  was  twentv-six  davs. 


ACUTE    SUPPURATIVE   OTITIS    MEDIA  275 

as  previously  described  for  the  treatment  of  acute  catarrhal  otitis  media 
(see  p.  259,  Fig.  146).  If,  however,  pus  is  present  in  quantity  at  the 
time  of  the  incision,  better  results  will  be  secured  by  frequent  irrigation 
of  the  auditory  canal  with  one  of  the  milder  antiseptic  ear  solutions, 
after  the  plan  already  pointed  out. 

During  the  progress  of  the  disease  subsequent  to  spontaneous 
rupture  or  incision  of  the  membrana,  the  latter  structure  should  be 
frequently  examined  by  means  of  the  aural  speculum  and  reflected 
light,  when  the  amount  of  infiltration  of  the  parts  and  the  color  of  the 
drum  membrane  should  be  carefully  noted.  The  size  of  the  perforation 
should  also  be  observed,  and  if  found  to  be  closing  too  rapidly,  at  the 
same  time  that  pain  and  fever  returns,  a  secondary  incision  should  be 
performed  at  once.  It  sometimes  happens,  owing  to  the  anatomical 
arrangement  of  the  mucous  folds  found  in  the  attic,  or  to  the  formation 
of  adhesions  that  wall  off  one  portion  of  the  tympanic  cavity  from 
another,  that  a  pocket  of  pus  will  form  independently  of  the  main  tym- 
panic cavity,  and,  therefore,  a  good  opening  may  be  seen  through  the 
membrana,  whereas  fever  and  pain  will  continue  as  a  result  of  the  re- 
tention of  pus  in  the  unopened  pocket.  In  such  case  a  careful  exam- 
ination will  be  sufficient  to  detect  the  bulging  area,  which  should  be 
freely  incised  and  drained. 

Those  suffering  from  this  disease  should  usually  remain  in  doors 
and,  during  the  height  of  the  inflammation,  in  bed.  During  the  height 
of  the  inflammation  of  the  middle-ear  tract  the  mucous  membrane  is 
hypersensitive  to  the  temperature  changes  to  which  the  patient  is  exposed 
should  he  be  allowed  to  be  up  and  around,  a  fact  which  is  frequently 
demonstrated  by  exacerbations  of  the  disease  which  follow  even  the 
most  trivial  exposure.  Stuffy,  overheated,  and  poorly  ventilated  quarters 
are  to  be  avoided,  whereas  an  equable  temperature  and  a  well-ventilated 
room  are  conducive  to  the  best  results.  The  patient  should  lie,  after 
perforation  or  rupture  of  the  drum  membrane,  upon  the  affected  side 
and  with  the  face  somewhat  downward,  since  this  position  favors  the 
most  perfect  drainage.  Systemic  medication  and  local  treatment  of  the 
nose  and  throat  are  always  helpful  and  often  most  essential,  and  should 
be  carried  out  after  the  plans  detailed  in  another  section  of  the  work. 
The  treatment  of  mastoiditis,  which  frequently  accompanies  or  follows 
this  disease,  is  also  given  in  Chapter  XXV. 

In  case  the  disease  is  first  seen  at  a  later  stage,  or  should  failure  to 
cure  have  resulted  from  employment  of  the  above  measures,  the  use 
of  astringents  in  the  middle  ear  often  prove  beneficial  and  arrest  the 
progress  of  the  ailment  before  it  has  become  chronic.  The  most  efficient 


276  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

of  this  class  of  remedies  is  silver  nitrate,  but  in  order  to  secure  the  best 
results  from  its  use  certain  rules  must  be  followed.  In  the  first  place 
the  irrigating  solutions  that  have  been  previously  used  must  be  washed 
away  with  distilled  water  and  the  auditory  canal  afterward  dried; 
catheter  inflation  of  the  middle  ear  should  be  performed  and  the  fluid 
contents  of  whatever  nature  should  be  blown  through  the  perforation 
into  the  external  auditory  canal,  and  mopped  away  by  means  of  cotton 
cylinders.  Silver  solution  should  not  be  used  stronger  than  5  gr. 
to  the  ounce  in  the  beginning.  The  patient  lies  upon  a  cot  with  the 
diseased  ear  uppermost,  a  few  drops  of  the  silver  lotion  are  dropped 
into  the  canal,  and  the  auricle  is  then  retracted  and  the  canal  straight- 
ened by  lifting  the  pinna  upward  and  backward  with  one  hand,  while 
with  the  other  the  tragus  is  pressed  into  the  concha  repeatedly,  so  as  to 
force  the  drops  through  the  perforation  into  the  tympanic  cavity.  By 
means  of  this  manipulation  the  lotion  is  driven  into  all  the  recesses  of 
the  middle  ear  and  quickly  penetrates  through  the  Eustachian  tube  into 
the  nasopharynx.  When  the  perforation  in  the  drum  membrane  is 
quite  small  the  employment  of  this  procedure  is  unsuccessful  and  the 
opening  should  be  enlarged  by  an  incision.  The  silver  solution  may 
also  be  carried  into  the  cavum  tympani  by  means  of  a  properly  con- 
structed aural  pipette,  the  end  of  which  is  passed  through  the  perforation, 
after  which  2  or  3  drops  of  the  solution  are  expressed.  After  the 
introduction  of  the  silver  by  either  of  these  methods,  any  excess  of  the 
solution  should  be  syringed  out  of  the  canal,  normal  salt  solution  being 
used  for  this  purpose.  This  not  only  neutralizes  the  further  action  of 
the  silver  but  also  prevents  the  discoloration  of  the  visible  portions  of 
the  ear,  a  most  objectionable  feature  of  silver  preparations  unless  some 
such  preventive  measures  as  are  here  mentioned  are  employed.  In 
cases  where  the  discharge  has  been  kept  up  by  the  presence  of  superficial 
ulceration  of  the  soft  parts,  the  use  of  this  antiseptic  and  astringent  fre- 
quently brings  about  a  speedy  cure.  On  the  other  hand,  if  deep-seated 
destruction  of  the  soft  tissues  has  occurred,  and  the  ossicles  or  bony 
walls  of  the  tympanic  cavity  are  exposed,  carious  or  necrotic,  great 
benefit  need  scarcely  be  expected  from  this  remedy,  and  the  disease 
becomes  chronic  unless  rational  operative  measures  are  instituted  for 
the  removal  of  the  diseased  areas. 

Since  efficient  treatment  of  the  acute  tympanic  affections  depends 
in  such  large  measure  upon  a  correct  diagnosis  of  the  particular  variety 
of  the  disease  which  may  be  present  in  any  case,  the  following  table  of 
the  leading  symptoms  present  in  each  may  prove  helpful  in  a  study  of 
the  subject. 


ACUTE    SUPPURATIVE    OTITIS   MEDIA 


277 


DIFFERENTIAL  DIAGNOSIS  OF  ACUTE  TUBOTYMPANIC  CATARRH,  ACUTE 
CATARRHAL  OTITIS  MEDIA,  AND  ACUTE  SUPPURATIVE  OTITIS 
MEDIA 


Pain. 


Fever. 


Deafness. 


Acute  Tubolympanic 
Catarrh 

Absent  in  the  ear;  usually 
amounts  only  to  a  sense 
of  soreness  in  throat,  as 
of  foreign  body.  More 
or  less  pain  along  course 
of  Eustachian  tube. 

Absent,  unless  the  tubo- 
tympanic  catarrh  is  sec- 
ondary to  some  other 
ailment,  as  a  mild  form 
of  measles,  which  pri- 
mary disease  gives  rise  to 
the  fever. 


Acute  Catarrhal  Olitis 
Media 

Severe  in  depths  of  the  ear, 
radiating  over  side  of 
head.  Worse  on  lying 
down.  Pain  increased 
by  blowing  nose  or 
cough.ng. 

Temperature  usually  ele- 
vated, ioo°-ioi°  F.  in 
infants  and  young  chil- 
dren. 


Moderate.       Patient   com-    Very  considerable  in  affect- 
plains  of  great  deafness,         edear. 
however,  largely  because 
of     the     suddenness     of 


Acute  Suppurative  Olitis 
Media 

Very  severe,  of  lancinating, 
tearing  variety.  In- 
creased by  recumbent 
position,  by  coughing, 
sneezing,  blowing  of  the 
nose,  etc. 

Ranges  from  102°  to 
104°  F.,  the  height  of 
temperature  depending 
much  upon  the  presence 
of  some  general  disease, 
as  measles,  scarlet  fever, 
or  la  grippe. 

Very  great  in  affected  ear. 
Patient  very  deaf  when 
both  ears  are  involved. 


Prostration     of  None, 

patient. 

Tinnitus,  vertigo,  etc.     Present  and  often  severe. 


Usually  moderate.      Some-     Often  very  great, 
times  considerable. 


Drum   membrane. 


Perforation. 
Discharge. 

Tympanic  cavity. 

Tympanic  inflation. 
History. 


Mastoid 

complication. 


Head  noises  not  a  promi- 
nent symptom  except  in 
later  stages,  after  the  pain 
and  fever  have  subsided. 
Vertigo  and  nausea  r;«re. 

Little  or  not  at  all  retracted 
at  onset,  later  is  bulging 
over  some  quadrant.  In- 
jected at  first,  and  later 
a  diffuse  uniform  redness 
covers  whole  membrane. 
Landmarks  usually  all 
obliterated  with  possible 
exception  of  short  pro- 
cess of  the  malleus. 


Greatly  retracted  in  first 
stage,  less  so  in  second 
stage.  Inflammation  ab- 
sent, vessels  along  handle 
of  malleus  sometimes 
injected.  After  exuda- 
tion into  the  tympanic 
cavity  has  occurred,  a 
dark,  or  sometimes  a 
light  line  may  he  seen 
crossing  membrane,  and 
indicating  level  of  fluid. 
All  landmarks  present. 

Drum    membrane    seldom     Drum    membrane    usually 
ruptured.  perforated  after  from  one 

to  three  days. 

None  except  after  paracen-    Thin  seromucous  discharge 

tesis.  immediately  after  rupture 

or    paracentesis.       May 

later     become     purulent 

from  infection. 


Rarefied  in  first  stage.  In 
second  stage  frequently 
contains  a  yellowish  se- 
rum, or  ropy  mucoid 
exudate,  which  is  visible 
through  non-inflamed 
membrana  tympani. 

Not  painful.  Immediate 
and  marked  improve- 
ment results  to  hearing. 

Usually  accompanies  or 
follows  a  cold  in  the  head 
or  a  nasopharyngitis. 
May  result  from  mild 
attacks  of  exanthemata 
or  tonsillitis. 

» 

Never  occurs. 


Contains  seromucous  exu- 
date, which  bulges  mem- 
brane, but  is  not  visible 
through  inflamed  mem- 
brane. 


Painful.  Little  or  no  im- 
provement in  hearing, 
except  in  later  stages. 

Accompanies  or  follows 
the  exanthemata  of  mod- 
erate severity,  and  the 
acute  tonsillar  and  naso- 
pharyngeal  inflamma- 
tions. 

Seldom  occurs. 


If  present  in  beginning  are 
so  masked  by  severe  pain 
that  they  are  not  men- 
tioned. Sometimes  pres- 
ent during  convalescence. 

Intensely  reddened,  espec- 
ially in  upper  portion; 
swollen,  bulging,  opaque. 
Landmarks  all  oblitera- 
ted. Drum  membrane 
may  be  largely  destroyed 
during  first  two  or  three 
days. 


Always   present   after  first 
two  or  three  days. 


Sanguinopurulent  at  mo- 
ment of  perforation,  pur- 
ulent later.  Usually 
very  profuse. 


Contains  pus.  Mucous 
membrane  greatly  swol- 
len, with  necrotic  areas 
in  worst  cases.  Incus 
and  hammer  sometimes 
carious. 


Painful,  and  should  seldom 
be  performed  during 
height  of  inflammation. 

Follows  or  accompanies 
the  more  violent  forms 
of  the  exanthemata,  la 
grippe,  ulcerative  ton- 
sillitis, diphtheria,  etc. 


Frequently   occurs. 


CHAPTER  XXIV 
ACUTE   MASTOIDITIS 

ACUTE  inflammation  of  the  osseous  structures  of  the  mastoid  process 
may  take  place  at  any  time  during  the  progress  of  an  acute  otitis  media, 
especially  of  the  suppurative  variety.  During  certain  epidemics  of  the 
exanthematous  diseases  and  of  la  grippe  the  mastoid  complication 
has  been  known  to  occur  with  great  frequency.  Extension  of  an  acute 
suppurative  inflammation  of  the  middle  ear  to  the  mastoid  antrum  and 
the  adjoining  cellular  labyrinth  of  the  mastoid  process,  is  in  all  cases 
an  occurrence  of  more  or  less  gravity,  adds  very  much  to  the  suffering 
of  the  patient,  and  greatly  decreases  both  the  immediate  and  remote 
chances  of  recovery.  The  affection,  therefore,  presents  one  of  the  most 
important  of  the  several  diseases  which  arise  in  the  temporal  bone, 
and  which  have  a  common  origin  in  an  existing  suppurative  process 
within  the  tympanic  cavity. 

Causation. — Acute  mastoiditis  is  in  nearly  every  instance  secondary 
to  a  previous  infection  and  suppuration  of  the  tympanic  cavity.  It  has 
been  estimated  that  not  over  i  per  cent,  of  all  the  cases  of  this  disease 
originate  in  the  mastoid  antrum  itself,  and  of  this  small  number  nearly 
all  cases  of  primary  mastoiditis  are  due  to  traumatism.  Certain  general 
diseases,  and  local  nose  and  throat  affections,  are  primarily  responsible 
for  acute  mastoiditis.  Among  the  former  may  be  mentioned  scarlatina, 
measles,  diphtheria,  and  la  grippe;  while  among  the  latter,  quinsy  and 
the  different  varieties  of  tonsillitis  may  be  cited.  In  general  it  may  be 
stated  that  the  more  violently  severe  the  middle-ear  infection,  the  more 
likely  is  a  mastoid  inflammation  to  follow  as  a  complication. 

Inefficient  drainage  of  a  suppurative  middle  ear  must  be  counted 
among  the  most  potent  determining  causes  of  mastoiditis.  When  the 
provision  for  the  outflow  of  pus  is  inadequate,  either  because  the  rupture 
through  the  drum  membrane  is  too  small  or  because  the  incision  was 
not  sufficiently  extensive,  pus  is  retained  in  the  tympanic  cavity  under 
more  or  less  pressure,  and  some  of  it  must  inevitably  find  its  way  into 
the  mastoid  antrum  where  a  secondary  focus  of  infection  is  established. 
In  view  of  the  fact  that  the  cavities  of  the  mastoid  antrum  and  middle 
ear  lie  in  such  open  communication  with  each  other  (Fig.  150),  it  is  quite 

278 


ACUTE   MASTOIDITIS  279 

probable  that  in  all  cases  of  tympanic  suppuration  in  which  the  drain- 
age is  not  entirely  free,  that  pus  from  the  middle  ear  finds  its  way  into 
the  mastoid  antrum,  and  that  as  a  result  mastoiditis  is  quickly  estab- 
lished unless  the  tympanic  drainage  is  speedily  improved. 

The  greatly  lowered  vitality  of  the  patient  who  suffers  from  a  severe 
attack  of  aural  suppuration  is  without  question  a  factor  in  the  establish- 
ment of  a  mastoiditis,  for  when  an  individual  has  undergone  great  pain 
as  the  result  of  some  general  disease,  in  which  a  middle-ear  suppuration 
has  also  taken  place,  the  mucous  lining  of  the  mastoid  antrum  is  un- 
doubtedly less  resisting  to  the  invasion  of  pathogenic  bacteria  than  is 
the  case  when  the  tympanic  inflammation  results  from  some  local 
affection  of  the  throat,  in  which  less  pain  and  constitutional  disturbance 
is  manifest. 

Elevation  of  tympanomastoid  semicircular  Mastoid  antrum 

canal  in  aditus  ad  antrum  \  Cerebral 

Oval  wii 
Canal  for  tensor  tympani  mu< 

Osseous  Eustachian  tube 

Facial  canal  at  point  of 
turning  backward 

Carotid  canal 
Annulus  tympan 

External  auditory  meatus 

Glenoid  fossa 


FIG.  150. — SECTION  OF  TEMPORAL  BONE  IN  PLANE  OF  MASTOID  ANTRUM.     ADITUS,   TYMPANUM,   AND 
EUSTACHIAN  TUBE,  SHOWING  DIRECT  CONNECTION  OF  ALL  THESE  SPACES. 

Diagnosis. — The  diagnosis  of  acute  mastoiditis  must  be  determined 
by  the  physical  condition  of  the  patient;  by  the  manifestation  of  the 
presence  of  underlying  disease  as  indicated  by  external  changes  in  the 
tissues  over  the  mastoid  and  around  the  external  ear;  by  the  physical 
changes  that  have  taken  place  at  the  bottom  of  the  auditory  canal,  and 
in  the  drum  membrane  and  middle  ear,  as  shown  by  actual  inspection 
of  these  parts  by  means  of  reflected  light  and  the  use  of  instruments 
when  necessary. 

i.  The  Physical  Condition  of  the  Patient. — In  most  instances  of  acute 
mastoiditis  it  will  be  found  that  the  middle-ear  suppuration  which  is 
responsible  for  the  mastoid  complication  has  been  of  more  than  the 
average  violence,  and  that,  unless  the  mastoiditis  developed  soon  after 
the  beginning  of  the  middle-ear  involvement,  the  patient  is  more  greatly 
prostrated  than  would  have  been  the  case  had  the  sole  disease  been 
nothing  more  than  a  simple  aural  inflammation.  In  cases  where  the 


280  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

extension  of  the  inflammation  to  the  mastoid  occurs  several  days  after 
the  beginning  of  the  tympanic  disease,  it  is  usually  found  that  the  dis- 
charge from  the  ear  has  at  no  time  since  its  appearance  shown  any 
tendency  to  lessen,  or  if  it  has  done  so,  that  there  was  at  once  set  up,  as 
a  result  of  the  pus  retention,  a  decided  increase  of  pain  in  the  ear  and 
over  the  temporal  region.  Anemia,  due  to  the  continued  and  severe 
pain,  with  the  consequent  loss  of  sleep  and  disturbed  digestion,  is  often 
so  marked  as  to  be  suggestive  of  a  more  serious  affection  than  a  simple 
otitis  media.  The  temperature  may  vary  greatly  in  different  cases 
and  during  the  different  stages  of  the  same  case.  When  the  mastoiditis 
comes  on  during  the  continuance  of  the  general  disease  which  is  respon- 
sible for  the  middle-ear  suppuration,  the  temperature  may  reach  103°  F. 
or  even  105°  F.  In  such  instance,  however,  the  high  temperature  is 
due  largely  to  the  causative  general  disease,  as,  for  instance,  measles, 
scarlatina,  or  la  grippe,  and  not  so  much  to  the  complicating  mastoiditis. 
Should  this  latter  complication  arise  subsequently  to  the  subsidence 
of  the  general  disease,  as  is  often  the  case,  the  temperature  may  be  but 
little  or  not  at  all  elevated.  Mastoiditis  in  which  considerable  destruc- 
tion of  tissue  has  resulted  is  sometimes  observed  in  cases  in  which  the 
temperature  remains  normal.  In  the  case  of  infants  or  very  young 
children  the  temperature  may  be  considerably  elevated  at  the  beginning 
of  the  mastoid  complication,  whereas  subsequently  there  may  be  a 
normal  or  even  subnormal  temperature,  even  though  a  large  post- 
aural  abscess  is  present. 

2.  The  External  Manifestations  Over  the  Mastoid  Region. — Swelling 
of  the  soft  tissues  over  the  mastoid  region  occurs  only  after  the  pus  which 
has  collected  in  the  mastoid  cells  has  ruptured  through  the  exterior  bony 
walls,  or  after  an  inflammation  and  infiltration  of  the  soft  structures 
which  cover  the  bony  cortex  has  taken  place  as  a  result  of  the  transporta- 
tion of  septic  material  from  the  infected  interior,  through  the  vascular 
channels,  to  these  superficial  structures.  A  postauricular  tumefaction 
should,  therefore,  not  be  expected  to  occur  as  a  result  of  mastoiditis 
until  the  suppuration  has  existed  in  the  mastoid  process  for  several 
days.  Such  a  swelling  does  not  occur  at  all  in  many  cases  even  though 
the  mastoiditis  continues  into  the  chronic  form.  The  author  has 
repeatedly  found  both  the  mastoid  cells  and  antrum  filled  with  pus 
at  the  time  of  the  mastoid  operation,  when  not  the  slightest  external 
swelling  had  previously  existed  to  indicate  its  presence.  Swelling 
above  and  behind  the  auricle  sometimes  occurs  as  a  complication  of 
either  a  circumscribed  or  diffuse  external  otitis.  As  has  already  been 
pointed  out  in  the  chapters  on  these  subjects,  either  a  boil  or  a  general 


ACUTE   MASTOIDITIS 


28l 


inflammation  of  the  external  auditory  canal  will,  when  severe,  often 
be  accompanied  by  a  tumefaction  behind  the  auricle  which  is  sufficient 
to  cause  protrusion  of  the  ear  and  to  give  a  deformed  appearance  to  the 
individual's  head.  To  the  casual  observer  this  condition  looks  identical 
to  that  produced  by  the  postaural  swelling  which  sometimes  takes  place 
during  a  mastoiditis  (see  Fig.  181),  but  the  examiner  can  usually  differ- 
entiate the  one  from  the  other  if  he  will  only  remember  that  manipula- 
tion of  the  auricle  is  accompanied  by  very  severe  pain  in  case  the 
swelling  is  due  to  an  inflammation  which  is  located  in  the  external 
auditory  canal,  whereas  if  it  be  due  to  an  underlying  suppuration  of 


FIG.  151. — POINTS  OF  MASTOID  TENDERNESS  IN  ACUTE  MASTOIDITIS. 

The  uppermost  X  is  over  the  site  of  the  mastoid  antrum,  the  lower  one  is  over  the  mastoid  tip,  and  the 
posterior  one  is  over  the  point  of  exit  of  the  mastoid  vein.  The  hair  of  the  whole  head  is  clipped  close  and  the 
mastoid  region  is  closely  shaved  preparatory  to  the  mastoid  operation. 

the  bone,  as  is  the  case  in  mastoiditis,  the  auricle  can  be  retracted  or 
otherwise  handled  without  causing  the  slightest  suffering  to  the  patient. 
Mastoid  tenderness  is  almost  constantly  present,  but  except  in  the 
more  severe  cases,  and  where  there  is  an  accompanying  periosteal 
inflammation  over  the  mastoid  process,  this  tenderness  is  usually  con- 
fined to  three  small  postauricular  areas.  The  first  and  most  common 
point  of  tenderness  can  be  covered  by  the  ball  of  the  finger  and  lies 
directly  over  the  site  of  the  mastoid  antrum.  As  will  be  seen  by  the 
external  markings  which  indicate  the  position  of  this  cavity,  and  as 


282 


THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


shown  upon  the  surface  of  the  skull  by  the  suprameatal  triangle 
(see  Fig.  165),  this  area  lies  just  behind  the  attachment  of  the  auricle 
and  slightly  above  the  posterosuperior  border  of  the  external  meatus. 
The  second  area  of  greatest  tenderness  is  over,  and  sometimes  beneath, 
the  tip  of  the  mastoid  process  (Fig.  151).  The  third  point  of  tenderness 
lies  over  the  exit  of  the  mastoid  vein  (Fig.  151).  In  that  type  of  mastoid 
process  in  which  the  mastoid  cells  are  large,  and  consequently  lie  near 
the  surface  (Fig.  152),  the  amount  of  pain  resulting  from  deep  pressure 
over  the  mastoid  tip,  especially  during  the  height  of  the  suppurative 


Outer  part  external  auditory 
meatus 


Groove  for  branch  middle 
meningeal  artery 


Middle  cerebral  fossa 
Tegmen  celluli 

Thick  cortex 


Mastoid  cortex 


FIG.  152. — OUTER  PORTION  OF  A  SECTION  or  THE  TEMPORAL  BONE  ON  A  PLANE  EXTERNAL  TO  THE  TYMPANIC 

CAVITY  AND  MASTOID  ANTRUM. 
Specimen  shows  large  cells  at  the  mastoid  tip.     Bezold's  abscess  is  favored  by  this  type  of  mastoid. 

period,  is  usually  very  considerable.  On  the  contrary,  if  the  bony  cortex 
is  thick,  and  the  mastoid  cells  are  but  slightly  developed  (Fig.  153),  the 
tenderness  on  pressure  may  be  correspondingly  less  marked.  In  testing 
any  of  the  above  situations  for  tenderness,  the  pressure  of  the  examining 
finger  should  be  firm  and  prolonged  for  a  few  seconds.  Rude  manipula- 
tion in  the  examination  of  the  mastoid  is  apt  to  be  painful,  even  when 
the  underlying  structures  are  entirely  normal,  and  some  individuals 
are  so  unduly  sensitive  to  pressure  exerted  over  this  region  that  the 
rule  should  be  followed  hi  all  instances  of  suspected  mastoiditis  to  make 


ACUTE    MASTOIDITIS 


283 


exactly  similar  pressure  over  the  mastoid  of  the  healthy  side,  for  by 
exercising  this  precaution  the  examiner  is  able  to  determine  whether 
or  not  the  pain  elicited  by  the  examination  of  the  presumably  diseased 
mastoid  is  or  is  not  normal.  In  testing  the  sensibility  of  the  mastoid 
tip  it  is  essential  to  hook  the  finger  around  the  lower  end  of  this  projec- 
tion and  into  the  digastric  fossa  as  much  as  possible,  in  order  that  the 
desired  pressure  may  be  exerted  in  an  upward  direction  and  against  the 
large  cellular  space  that  often  fills  the  point  of  the  apophysis  (see  Fig. 
152).  By  carefully  executing  this  procedure  exquisite  tenderness  is 


Groove  for  lateral  sinus  -{ 


|-  Thick  cortex 


Deep-seated  mastoid  cells 


Tegmen 


Digastric  groove 


FIG.  153. — SECTION  OF  MASTOID  POSTERIOR  TO  STYLOMASTOID  FORAMEN. 
Note  the  thick  cortex  and  the  comparatively  thin  legmen.     Compare  this  drawing  with  Fig.  152. 

sometimes  discovered  that  would  otherwise  have  been  entirely  over- 
looked. 

3.  Changes  thai  Have  Taken  Place  at  the  Inner  End  of  the  Auditory 
Canal,  in  the  Membrana  Tympani,  and  in  the  Middle  Ear  Itself,  which 
May  be  Determined  Only  by  a  Thorough  Examination  of  the  Depths  of 
the  Ear. — The  upper  and  posterior  portion  of  the  inner  end  of  the 
external  auditory  meatus  lies  in  close  relation  to  the  adjoining  cellular 
structure  of  the  mastoid  process.  It  follows,  therefore,  that  when  the 
adjacent  cells  of  this  process  are  distended  by  inflammatory  exudate  or 
pus  that  sagging  of  this  portion  of  the  canal  wall  will  take  place  (Fig. 
154).  Such  a  swelling  of  the  inner  end  of  the  meatal  wall  is  not  con- 
stantly present  in  acute  mastoiditis  but  in  the  author's  cases  has  been 


284  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

observed  in  a  majority  of  instances.  Numerous  authors  have  spoken  of 
this  sagging,  when  present,  as  a  pathognomonic  symptom  of  mastoiditis. 
A  perforation  in  the  tympanic  membrane  will  most  likely  be 
present  in  one  of  the  superior  quadrants,  and  in  the  acute  cases  of 
mastoiditis  the  rupture  is  usually  small  and  therefore  provides  inefficient 
drainage  for  the  rather  considerable  suppurating  area  beyond.  When 
the  bead  of  pus  which  fills  the  opening  is  mopped  away  by  means  of  a 
cotton-tipped  applicator,  another  will  be  seen  to  take  its  place  almost 
immediately,  the  discharge  thus  appearing  much  more  profuse  than 
in  uncomplicated  cases  of  otitis  media  purulenta.  Politzer  has  called 
attention  to  a  pulsating  light  reflex  which  may  frequently  be  seen  on 
the  drop  of  pus  which  fills  the  perforation,  and  he  believes  that  when 


FIG.  154. — SAGGING  OF  THE  POSTEROSUPERIOR  WALL  AT  THE  INNER  END  OF  THE  EXTERNAL  AUDITORY 

MEATUS,  THE  RESULT  OF  MASTOID  SUPPURATION  IN  THE  ADJACENT  PNEUMATIC  CELLS  OF  THE  MASTOID. 

Compare  location  of  the  sagging  with  tumefaction  of  canal  due  to  furuncle  (see  Fig.  74). 

this  pulsation  continues  to  be  present  after  the  continuance  of  the 
discharge  for  a  period  of  two  weeks  from  the  date  of  the  rupture  of  the 
drum-head,  that  the  same  is  indicative  of  a  complicating  mastoid  abscess. 
The  author  has  confirmed  this  belief  in  many  instances,  and  attaches 
considerable  importance,  in  a  diagnostic  way,  to  the  presence  of  the 
pulsating  reflex,  especially  if  present  in  conjunction  with  other  symptoms. 
In  those  violent  middle-ear  suppurations  which  so  often  complicate 
scarlet  fever,  the  middle  ear,  mastoid  antrum,  and  mastoid  cells  are, 
no  doubt,  frequently  involved  simultaneously,  as  in  such  instances  it  is 
not  uncommon  to  find  that  the  drum  membrane  and  ossicles  have  been 
entirely  swept  away,  thus  providing  for  ample  drainage,  but  not  before 
necrosis  of  the  soft  and  bony  tissues  of  the  middle  ear  and  mastoid  have 
taken  place. 


ACUTE   MASTOIDITIS  285 

Not  all  or  even  a  majority  of  the  above  diagnostic  points  are  found 
in  every  case  of  acute  mastoid  suppuration.  Those  upon  which  most 
reliance  is  usually  placed  are:  tenderness  upon  pressure  over  the 
site  of  the  antrum,  mastoid  tip,  and  exit  of  the  mastoid  vein,  the  presence 
of  a  profuse  unchecked  discharge,  the  pulsating  light  reflex  at  the  point 
of  rupture  in  the  drum  membrane,  and  the  sagging  of  the  posterosuperior 
meatal  wall.  In  any  case  in  which  the  discharge  from  the  ear  is  profuse 
and  persists  beyond  two  weeks  without  perceptibly  diminishing  in 
quantity,  when  the  pain  is  unduly  severe,  interfering  with  sleep  at  night, 
and  when  there  is  more  fever  and  general  prostration  than  should 
accompany  an  uncomplicated  middle-ear  suppuration,  acute  mastoiditis 
may,  with  reasonable  certainty,  be  diagnosed  even  though  postauricular 
swelling  and  tenderness  are  not  present. 

Prognosis. — The  termination  of  acute  mastoidits  is  nearly  always 
favorable  provided  the  present  well-known  and  efficient  means  of 
treatment  are  applied  sufficiently  early.  Left  untreated,  it  is  sometimes 
a  fatal  malady.  Politzer  has  demonstrated  that  pus  is  present  in  the 
pneumatic  spaces  of  the  mastoid  process  in  most  cases  of  suppuration 
of  the  middle  ear,  and  a  study  of  the  anatomic  relation  of  the  labyrinth 
of  cavities — the  middle  ear,  mastoid  antrum,  and  mastoid  cells — clearly 
shows  the  likelihood  of  such  an  occurrence  in  any  case.  The  mere 
presence  of  pus  in  the  mastoid  cells  does  not,  however,  constitute  a  mas- 
toiditis, for  it  is  only  when  the  parts  are  greatly  inflamed  and  suppurating 
and  the  pus  is  retained  under  pressure  that  the  disease  under  con- 
sideration may  be  said  to  be  present.  Many  of  the  milder  mastoid 
inflammations  subside  after  the  establishment  of  better  drainage  through 
the  perforated  drum  membrane,  the  inflammatory  deposits  which  have 
already  taken  place  within  the  cellular  structure  of  the  mastoid  being 
in  time  fully  removed  by  absorption.  If,  however,  the  drainage  from 
the  cells  into  the  mastoid  antrum,  from  the  antrum  into  the  middle  ear, 
and  finally  from  this  latter  cavity  through  the  perforated  tympanic 
membrane  is  at  any  point  seriously  impeded,  the  pus  retention  may 
result  in  pressure  necrosis,  and  consequent  rupture  of  the  pus  through 
the  bony  walls  may  take  place  (a)  outwardly  upon  the  external  surface 
of  the  mastoid,  producing  a  subperiosteal  abscess  behind  the  auricle  (Fig. 
181);  (b)  through  the  tegmen  tympani  into  the  middle  cranial  fossa, 
causing  a  cerebral  abscess  (Fig.  155);  (c)  backward  into  the  cerebellar 
space  or  lateral  sinus  with  cerebellar  abscess  formation,  or  lateral  sinus 
thrombosis  (Fig.  155),  and  finally  (d)  rupture  into  the  digastric  fossa  with 
escape  of  pus  into  the  tissues  of  the  neck,  and  giving  rise  to  a  Bezold's 
.abscess  (see  Figs.  179  and  180).  Infection  of  the  cranial  contents 


286  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

through  a  fistula  caused  by  necrosis  of  the  intervening  tissues  is  rare  in 
acute  middle-ear  suppuration.  Rupture  of  the  pus  outward  upon  the 
mastoid  surface  or  into  the  digastric  fossa  is  much  more  common. 

The  lymphatic  and  venous  communications  between  the  structures 
of  the  temporal  bone  and  cranium  are  intimate,  and  septic  material  is 
sometimes  carried  to  the  brain  and  its  coverings  through  these  channels, 
the  result  being  a  localized  or  general  meningitis,  a  cerebral  or  cerebeUar 
abscess.  Thrombosis  of  either  the  superior  or  inferior  petrosal  vein 
or  of  the  sigmoid  sinus  may  also  result  from  the  adjacent  mastoid  suppu- 
ration. While  these  intracranial  complications  are  by  no  means  rare, 
they  do  not  follow  the  acute  aural  suppurations  nearly  so  frequently  as 
is  the  case  in  the  chronic  forms  of  mastoid  disease. 


Axis  of  sinus  groove     _    _^^_  ^ 

|Internal  auditory 
meatus 


FIG.  155. — CARIES  OF  SIGMOID  SINUS  GROOVE. 

External  cortex  of  antrum.    Phlebitis  of  lateral  and  petrosal  sinuses  and  jugular  meningitis.    (Warren  Museum, 
Harvard  Medical  School.     J.  Orne  Green  Collection.) 

A  frequent  termination  of  acute  mastoiditis  is  the  establishment  of 
the  chronic  variety,  which  will  be  subsequently  described. 

Treatment. — The  management  of  this  disease  is  abortive  and 
operative.  If  seen  in  the  very  beginning  and  it  is  intelligently  treated 
by  the  physician,  many  of  the  milder  acute  mastoid  inflammations  are 
undoubtedly  aborted  or  cured  by  means  other  than  the  mastoid  opera- 
tion. Free  drainage  through  the  middle  ear  and  perforated  drum 
membrane  is  absolutely  essential  to  a  subsidence  of  the  inflammatory 
state  of  the  mastoid  antrum  and  cells.  The  first  duty  of  the  attendant 
is,  therefore,  to  ascertain  by  a  most  careful  examination  of  the  fundus 
of  the  ear  the  location  and  size  of  the  perforation  in  the  tympanic 
membrane,  and  if  this  is  not  already  sufficiently  large  or  is  not  favorably 
situated,  to  immediately  perform  a  free  paracentesis.  Following  this 
procedure  a  sterile  gauze  wick  is  inserted  directly  against  the  drum 


ACUTE    MASTOIDITIS 


287 


membrane  in  order  to  more  efficiently  empty  the  tympanic  cavity  of  its 
pent-up  contents  (see  p.  259,  Fig.  146). 

It  has  in  the  past  been  a  common  practise  to  apply,  in  all  cases  of 
mastoiditis,  an  ice-bag  (Fig.  156),  to  the  postauricular  region,  leaving  the 
same  on  constantly  for  a  period  of  from  one  to  several  days.  More  re- 
cently dry  heat  applied  by  means  of  the  hot-water  bottle  has  had  its 
advocates.  Either  cold  or  heat  when  continuously  applied  in  this  way 
for  twenty-four  or  thirty-six  hours  will  produce  a  sedative  effect  on  the 
pain,  and  in  the  earliest  stages  of  the  ailment,  no  doubt,  acts  favorably 
upon  the  inflammatory  process.  The  question  as  to  which  of  the  two, 
heat  or  cold,  shall  be  applied  in  any  given  case,  should  be  largely  deter- 
mined by  the  individual  preference  of  the  patient.  Whichever  one  is 
used  should  not  be  kept  on  con- 
tinuously for  more  than  twenty- 
four  hours,  or  at  most  thirty- 
six  hours,  for  the  reason  that 
the  benumbing  effect  which  is 
produced  will  often  so  mask  the 
necrotic  progress  of  the  disease 
within  the  bone  that  both  the 
attending  physician  and  the 
patient  may  believe  that  all  is 
well,  whereas  the  exactly  oppo- 
site condition  possibly  prevails. 
Therefore  after  either  of  these 
measures  has  been  applied  con- 
tinuously for  a  day,  the  same 
should  be  discontinued  for  one 
night,  when  if  the  pain  returns 
in  its  former  severity,  the  fact 
would  be  highly  significant  of 

an     Unfavorable    progress.       On         FlG    I56._sPRAGUE's  AURAL  ICE  OR  HOT-WATER  BAG. 

the  other  hand,  if  the  former 

suffering  does  not  return  at  all  or  only  mildly,  this  fact,  taken  in  connec- 
tion with  the  coincident  betterment  of  other  conditions  should  be  looked 
upon  favorably,  and  the  mastoid  .heat  or  cold  may  be  again  employed. 
The  use  of  morphin  or  other  form  of  opiate  is  sometimes  advisable 
and  at  times  urgently  demanded.  The  patient  should  not  be  kept  under 
its  continuous  influence  for  the  same  reason  that  has  just  been  given  in 
the  case  of  the  prolonged  applications  of  heat  or  cold.  However,  the 
author  believes  it  advisable  at  the  onset  of  acute  mastoiditis,  if  the 


288  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

accompanying  pain  is  severe,  to  administer  a  small  hypodermic  of  mor- 
phin,  which  should  not  be  repeated  until  sufficient  time  has  elapsed 
for  its  full  effects  to  have  passed  off,  at  which  time  the  amount  of  mastoid 
pain  can  again  be  noted  independent  of  the  masking  influence  of  an 
opiate  or  local  application.  Applications  of  iodin,  the  inunction  of 
mercurials,  or  the  use  of  blisters  over  the  mastoid  surface  are  not  advisable, 
especially  after  the  first  few  hours  subsequent  to  the  onset  of  the  mas- 
toid itis.  The  application  of  a  blister  should  especially  be  condemned 
for  the  reason  that  it  creates  so  much  external  soreness  that  subsequent 
examinations  are  interfered  with,  and  the  pain  resulting  from  the  blister 
will  be  so  confused  with  that  which  is  due  to  the  mastoid  inflammation 
that  an  intelligent  estimate  of  the  progress  of  the  disease  is  subsequently 
impossible. 

Mention  need  scarcely  be  made  of  the  requirement  that  a  patient 
suffering  from  mastoiditis  shall  remain  indoors  and  preferably  in  bed. 
The  suppurating  middle  ear  should  receive  the  same  attention,  as  con- 
cerns its  irrigation  and  other  medication,  that  has  already  been  outlined 
in  the  chapter  on  Acute  Suppurative  Otitis  Media  (see  p.  272).  Attention 
to  the  alimentary  and  digestive  tracts,  if  the  same  has  not  been  pre- 
viously given,  is  early  indicated  in  the  complication  under  consideration. 
The  bowels  should  be  emptied  by  the  administration  of  salines  and 
the  patient  should  be  put  upon  a  limited  but  nourishing  diet. 

In  the  event  the  patient  fails  to  improve  as  a  result  of  the  application 
of  the  foregoing  measures,  or  grows  worse  during  the  continuance  of 
this  treatment,  the  mastoid  operation  is  indicated.  The  length  of  time 
which  should  be  devoted  to  efforts  directed  to  aborting  the  disease 
and  rendering  mastoid  surgery  unnecessary  varies  with  each  case  or, 
certainly,  with  each  type  of  case.  In  some  the  inflammatory  invasion 
is  from  the  onset  so  violent  that  the  cellular  structure  of  the  mastoid 
may  be  broken  down,  the  cortex  perforated,  and  a  subperiosteal  abscess 
form  within  a  week,  whereas  in  the  milder  forms  such  an  event  may  be 
delayed  for  months  or  may  never  take  place,  the  mastoiditis  continuing 
into  the  chronic  form  and  the  patient  subsequently  suffering  only  from 
the  annoyance  incident  to  a  chronic  discharging  ear.  In  the  fulminating 
variety  of  the  disease  it  is  unwise  to  delay  operative  measures  longer 
than  two  or  three  days  or  at  most  a  week  after  a  thorough  examination 
has  demonstrated  the  extension  of  the  disease  to  the  mastoid  process. 
The  less  violent  cases  may  be  treated  for  a  week  or  ten  days  in  the  hope 
that  subsidence  of  the  inflammation  may  take  place,  and  yet  the  author 
believes  that  both  the  present  and  future  safety  and  comfort  of  the 
patient  is  usually  best  served  by  opening  the  mastoid  and  securing 


ACUTE    MASTOIDITIS  289 

perfect  drainage  at  an  earlier  date.  The  opinion  held  by  some  writers 
that  one  should  wait  for  the  appearance  of  redness  and  swelling  behind 
the  ear  or  for  intracranial  or  other  danger  signals  before  resorting  to 
surgical  measures  for  relief,  is  entirely  unwise,  unsurgical,  and  unsafe, 
since,  as  has  already  been  seen,  a  postauricular  tumefaction  usually 
denotes  that  perforation  of  the  cortex  has  already  taken  place  with  escape 
of  pus  to  the  subperiosteal  tissues,  and  intracranial  disease  would  cer- 
tainly point  to  a  transfer  of  septic  material  directly  through  a  rupture 
into  the  cranial  cavity  or  indirectly  by  means  of  the  vascular  com- 
munication. An  early  mastoid  operation  in  cases  where  it  is  clearly  a 
justifiable  procedure  has  the  double  advantage  of  checking  further 
destruction,  by  the  disease,  of  the  middle-ear  structures,  and  of  pre- 
venting further  and  dangerous  complications.  The  effect  of  this 


Thin  legmen 

^^jftHSCSF'    Jl  > 

•  Thick  cortex 


External  auditory 
meatus 


FIG.  157. — SECTION  OF  TEMPORAL  BONE  EXTERNAL  TO  TYMPANIC  CA\m4  AND  MASTOID  ANTRUM. 

Showing  marked  contrast  in  the  thickness  of  bone  which  separates  the  exterior  of  the  skull  from  the  cells  and 

that  which  separates  the  cranial  cavity  from  the  cells. 

operation  in  the  way  of  arresting  the  tympanic  suppuration  and  the 
consequent  preservation  of  function  in  the  affected  ear,  is  in  most  cases 
so  notable  that  the  mastoid  operation,  if  performed  to  secure  these 
results  alone,  is  often  justifiable  (see  p.  308). 

A  study  of  the  anatomic  environs  of  the  mastoid  structures  will  show 
(Figs.  152  and  157)  that  the  thickness  of  the  bone  covering  these  cells 
externally  is  as  great  and,  in  most  cases  much  greater,  than  that  which 
separates  the  cells  from  the  middle-cranial  fossa  above,  and  from  the 
sigmoid  sinus  posteriorly,  and  that,  therefore,  the  pressure  necrosis  which 
occurs  as  a  result  of  the  pent-up  pus  within  the  mastoid  cells  is  as  apt 
to  take  place  brainward  as  outward.  The  sacrifice  to  life  by  operative 
procrastination  in  those  clearly  operative  cases  of  mastoid  suppuration 
must,  even  at  the  present  time,  be  very  considerable. 

19 


CHAPTER  XXV 
THE  MASTOID  OPERATION  FOR   ACUTE   MASTOIDITIS 

THE  operation  here  described  differs  in  so  many  important  respects 
from  the  radical  mastoid  operation,  which  is  performed  for  the  cure  of 
chronic  mastoiditis,  that  the  author  believes  a  clearer  understanding 
concerning  the  technic,  and  the  extent  and  purpose  of  each  procedure 
may  be  imparted  by  describing  each  one  separately.  What  is  said, 
therefore,  in  this  chapter  pertains  only  to  the  surgical  methods  applicable 
to  acute  mastoiditis,  whereas  the  radical  mastoid  operation  is  discussed 
in  another  section  of  the  work  (see  Chapter  XXX.). 

Preparation  of  the  Patient. — On  the  evening  preceding  the  opera- 
tion, unless  the  bowels  have  already  been  thoroughly  cleansed,  sufficient 
saline  should  be  given  to  secure  one  or  more  watery  stools.  The  evening 
meal  should  consist  of  bouillon,  milk,  or  other  liquid  food,  and  no  break- 
fast whatever  should  be  allowed  on  the  morning  of  the  operation.  If 
pain  is  present  of  sufficient  intensity  to  interfere  with  sleep  during  the 
previous  night,  the  administration  of  morphin  hypodermically  is  indi- 
cated, and  its  use  in  securing  needed  rest  will  add  much  to  the  patient's 
resisting  powers,  both  at  the  time  of  the  operation  and  during  the  sub- 
sequent treatment. 

An  examination  of  the  heart,  lungs,  and  urine  ought  to  be  made  the 
previous  day  in  order  that  the  anesthetic  to  be  given  may  be  selected 
with  intelligence.  If  the  heart  "is  sound,  chloroform  is  preferable,  for 
the  reason  that  bleeding  is  much  less  profuse  during  its  administration 
than  is  the  case  when  ether  is  used.  The  hemorrhage  itself  is  usually  of 
little  consequence,  but  as  the  wound  deepens  during  the  progress  of  the 
operation,  the  capillary  oozing  that  takes  place  from  every  quarter 
during  ether  anesthesia  often  so  obscures  the  operative  field  as  to  greatly 
delay  the  work  or  to  render  its  progress  somewhat  hazardous.  Especially 
is  this  true  in  those  cases  where  the  soft  tissues  around  the  ear  are  greatly 
congested  and  swollen  at  the  time  of  the  operation,  and  it  is  in  just  such 
instances  that  the  use  of  chloroform,  when  not  contraindicated,  is  most 
helpful.  Chloroform  should  also  be  given  if  bronchitis  is  present  or  if 
the  urine  contains  albumin  or  casts.  If,  however,  the  heart's  action  is 

290 


THE    MASTOID    OPERATION   FOR   ACUTE   MASTOIDITIS  2QI 

irregular  or  feeble  or  if  valvular  lesions  are  present,  ether  is  much  safer, 
and  the  possibilities  of  annoyance  from  bleeding  during  its  administration 
should  not  interfere  with  its  employment. 

The  hair  should  be  shaved  from  the  head  of  .the  affected  side  for  a 
distance  of  from  a|  to  3  inches  around  the  attachment  of  the  auricle 
(see  Fig.  151).  If  the  patient  be  a  man,  it  is  advisable  to  have  the  re- 
maining hair  of  the  head  cut  short  with  clippers.  Women  often  object 
to  extensive  removal  of  the  hair,  but  no  such  objection  should  be  per- 
mitted to  influence  the  operator  to  attempt  so  important  a  surgical 
procedure  without  first  having  provided  a  clean  surgical  field;  and  this 
can  only  be  accomplished  by  clearing  the  hair  from  an  area  at  least  as 
far  from  the  auricle  as  above  designated.  If  the  surgical  necessity  for 
this  measure  is  fully  explained  to  the  patient  all  objection  to  this  plan  of 
preparation  of  the  operative  field  is  usually  withdrawn.  The  remaining 
hair  of  the  female  head  should  be  combed  horizontally  over  the  crown 
and  tightly  braided  upon  the  opposite  side,  since  this  disposition  of  it  has 
proven  effective  in  keeping  it  well  away  from  the  wound  during  the 
operation  and  at  subsequent  treatments. 

When  shaved,  the  parts  adjoining  the  auricular  attachment  are 
scrubbed  with  soap  and  water,  the  external  auditory  meatus  is  syringed 
with  bichlorid  solution  (1:4000),  a  sterile  gauze  wick  is  inserted  to  the 
bottom,  and  a  bichlorid  gauze  dressing  is  applied  over  all,  and  held  in 
place  by  a  roller  bandage  (Fig.  255).  This  dressing  is  not  removed  until 
the  patient  is  anesthetized,  when  the  parts  are  again  scrubbed  with 
tincture  of  green  soap  and  water,  then  rubbed  with  ether,  and  this  is  in 
turn  followed  by  an  alcohol  bath.  A  rubber  cap  or  a  wet  sterile  towel 
should  cover  the  balance  of  the  hairy  scalp,  and  sterile  towels  are  placed 
over  the  chest  and  about  the  neck. 

Operations  upon  the  mastoid  process  for  the  relief  and  cure  of  acute 
mastoiditis  should  if  possible  be  made  in  a  well-appointed  hospital.  This 
is,  however,  frequently  not  possible,  and  in  such  instances  careful  anti- 
septic preparations  should  be  made  at  the  home  of  the  patient.  Excellent 
results  are  often  obtained  after  the  home  operations,  provided  aseptic 
conditions  are  assured  and  a  good  light  can  be  provided  for  the  perform- 
ance of  the  work. 

Two  assistants  and  a  nurse  are  necessary.  The  first  assistant  con- 
stantly watches  the  progress  of  every  step  of  the  work;  he  removes  the 
chips  of  bone  the  instant  they  are  detached,  and  he  keeps  the  wound  free 
from  blood  by  frequently  mopping  it  dry  with  the  gauze  sponges.  The 
second  assistant  retracts  the  flaps  or  attends  to  other  duties  that  may  be 
assigned.  The  nurse  provides  all  needed  supplies  promptly,  rinses  the 


2Q2 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


instruments  as  they  may  be  soiled,  and  keeps  them  arranged  in  the 
particular  order  designated  by  the  operator. 

The  Operation. — The  initial  incision  (Fig.  158)  is  made  from  just 
below  the  center  of  the  mastoid  tip  to  a  point  slightly  posterior  to  and 
above  the  upper  attachment  of  the  auricle.  Throughout  its  course  the 
cut  follows  the  postauricular  groove,  parallel  to  it  and  at  a  distance 
of  about  |  inch  behind  it.  The  operator  stands  at  the  head  of 
the  table,  the  left  forefinger  outlines  the  mastoid  tip,  at  which  point  the 


FIG.  158. — INCISION  THROUGH  SOFT  TISSUES. 
Showing  second  stroke  of  knife  which  severs  the  periosteum  throughout  the  entire  length  of  wound. 

knife  (shown  in  Fig.  159)  is  inserted,  and  the  line  of  incision  is  quickly 
but  deeply  carried  through  its  course  to  its  upper  termination.  In  adult 
cases  firm  pressure  is  made  upon  the  knife,  which  is  held  with  the  blade 
almost  perpendicular  to  the  mastoid  surface.  In  very  young  children  car- 
tilaginous and  membranous  areas  still  exist  between  the  centers  of  ossifi- 
cation, and  therefore  the  initial  cut  must  be  made  with  a  lighter  touch 
lest  the  knife  enter  the  cranial  cavity.  The  first  stroke  of  the  knife 
usually  severs  the  tissues  down  to  the  periosteum  and  divides  one  or 
more  blood-vessels  which  require  clamping  with  artery  forceps  (Fig.  160). 
The  wound  is  then  dried,  when  a  second  cut,  following  the  exact  course 
of  the  first,  will  be  sufficient  to  penetrate  to  the  bone  at  every  point.  The 


THE   MASTOID   OPERATION    FOR   ACUTE   MASTOIDITIS 


293 


periosteotome  (Fig.  161)  is  then  carefully  inserted  under  the  periosteum  at 
the  middle  of  the  anterior  flap,  and  the  periosteum  is  separated  from  the 
bone  in  a  forward  direction  until  the  posterior  portion  of  the  superior 
and  posterior  walls  of  the  external  auditory  meatus  are  clearly  exposed 
to  view.  In  like  manner  the  periosteum  of  the  posterior  flap  is  lifted 


LULL 


FIG.  159. — MASTOID  KNIJE. 

from  the  bone  throughout  the  entire  extent  of  the  incision,  with  the 
exception  of  that  portion  which  lies  above  the  linea  temporalis,  which  is 
covered  by  the  temporal  muscle.  The  greatest  care  should  be  exercised 
by  the  surgeon  in  separating  the  periosteum  from  the  underlying  bone, 
for  if  this  is  performed  rudely  or  indifferently  the  periosteum  may  be 
torn,  shredded,  or  be  so  much  bruised  that  it  may  subsequently  become 


FIG.  160. — DIFFERENT  SIZES  AND  SHAPES  OF  ARTERY  FORCEPS  USED  IN  MASTOID  SURGERY. 

inflamed  or  slough,  and  will  therefore  fail  to  adhere  to  and  properly 
cover  the  exposed  portion  of  the  mastoid  process  during  the  healing  of 
the  wound.  To  the  mastoid  process  are  attached  the  sternomastoid,  the 
splenius  capitis,  and  longissimus  capitis  muscles,  the  fibers  of  which, 
together  with  their  aponeurosis,  must  be  separated  to  a  greater  or  less 


294 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


extent  by  means  of  the  blunt-pointed,  curved  scissors  (Fig.  162),  which  are 
caused  to  hug  the  bone  closely  until  the  muscular  attachments  are  free 
to  the  desired  extent.  Suitable  retractors  are  then  placed  in  such  position 
as  to  separate  the  flaps  and  expose  the  denuded  mastoid  process  to  its 
fullest  extent  (Fig.  163). 

It  is  unwise  in  any  case  to  attempt  to  perform  the  mastoid  operation 
through  a  small  incision  of  the  soft  tissues,  for  the  reasons  that  the  land- 
marks upon  the  surface  of  the  skull  cannot  be  seen  sufficiently  well,  and 

that  unnecessary  difficulty  is  experi- 
enced in  manipulating  the  instruments 
intelligently  and  safely  within  the 
narrow  space  thus  provided.  Hence, 
if  the  incision  just  described  proves 
insufficient  in  any  instance,  the 
operator  should  feel  no  hesitation  in 
making  a  second  one  backward  and 
at  right  angles  from  the  center  of 
the  first  for  a  distance  of  at  least 


FIG.  161. — TYPES  OF  PERIOSTEA  r,  ELEVATORS. 


FIG.  162. — -BLUNT-POINTED  CURVED  SCISSORS  FOR 
DETACHING  MUSCULAR  ATTACHMENTS  TO  MASTOID 
PROCESS. 


i  inch,  after  which  the  soft  parts  are  lifted  from  the  bone,  and  the 
posterosuperior,  and  postero-inferior  flaps  are  turned  respectively  upward 
and  backward,  and  downward  and  backward  (see  Fig.  240)  in  such  a  way 
as  to  greatly  increase  the  area  of  denuded  skull.  This  second  incision  is 
especially  indicated  in  those  cases  where  there  is  great  tumefaction  of 


THE   MASTOID    OPERATION    FOR   ACUTE   MASTOIDITIS 


295 


the  postaural  tissues,  which  thus  causes  the  bone  to  lie  deeply,  and  hence 
increases  the  difficulties  of  operating  through  a  small  opening.  The 
additional  incision  is  also  necessary  when  the  disease  in  the  underlying 
bone  is  extensive,  and  to  do  a  complete  operation  requires  a  wide  removal 
of  the  mastoid  osseous  structure.  The  author  has  never  seen  any 
unfavorable  results  follow  this  extensive  exposure  of  the  skull,  and  since 
the  advantages  arising  from  its  employment  in  the  items  of  safety  to  the 


Linea  temporalis  — 

Suprameatal  or 
mastoid  fossa 

Posterior  wall  external 
auditory  meatus 


Fibers  temporal  muscle 

Subcutaneous  tissue 
^Skin 

,_--  Periosteum,  reflected 
£-=•  Site  of  mastoid  antrum 


Posterior  rim  external 
I     meatus 


f?  Mastoid  process 


jg  Divided  fibers  stemo- 
i      mastoid  muscle 


FIG.  163. — THE  FIELD  FOR  THE  MASTOID  OPERATION  (ACUTE)  COMPLETELY  EXPOSED,  SHOWING  ALL  LAND- 
MARKS NECESSARY  TO  OBSERVE  DURING  THE  OPERATION. 

The  muscular  attachments  to  the  tip  of  the  mastoid  process  are  shown  cut  away  to  a  greater  extent  in 
this,  and  the  subsequent  illustrations,  than  is  usually  necessary.  In  all  the  drawings  of  the  mastoid  operations 
shown  in  this  work  the  periosteum  and  other  soft  tissues  are,  for  purposes  of  greater  clearness,  slightly 
exaggerated.  Observe  that  the  periosteum  is  not  incised  above  the  linea  temporalis,  and  that  the  fibers  of  the 
temporal  muscle  are  not  divided. 

patient  and  ease  of  operating  are  very  considerable,  he  employs  it  in  a 
constantly  increasing  number  of  his  operations. 

Although  the  hemorrhage  incident  to  the  operation  is  in  no  case 
severe  unless  the  sigmoid  sinus  should  be  accidentally  injured,  yet  in 
order  to  accomplish  the  successive  steps  of  the  procedure  speedily,  safely, 
and  accurately,  the  blood  must  be  frequently  mopped  from  the  wound  by 
an  assistant.  For  this  purpose,  several  sizes  of  gauze  sponges  are  most 
convenient,  the  largest  being  used  during  the  skin  incisions,  and  the 
smaller  and  still  smaller  ones  substituted  as  the  bony  opening  is  deepened 


296 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


A  moderately  slender  dressing-forceps  is  a  most  convenient  instrument 
(Fig.  164)  with  which  to  use  the  mops  rapidly  and  efficiently. 

Inspection  of  the  Landmarks  upon  the  Mas  to  id  Portion  of  the  Tem- 
poral Bone  which  are  Exposed  by  the  Primary  Incisions  ,(as  shown  in 
Fig.  163). — When  the  wound  is  thoroughly  dried,  certain 
landmarks  which  are  usually  present  must  be  sought  for 
and  their  position  afterward  borne  in  mind,  because  they 
form  important  guides  to  the  safe  and  speedy  entrance  into 
the  mastoid  antrum.  The  posterior  root  of  the  zygoma 
continues  backward  above  the  superior  margin  of  the 
external  meatus,  forming  a  ridge  that  can  be  seen,  or 
at  least  felt  with  the  examining  finger,  in  almost  every 
instance.  This  ridge  (Fig.  165,  i,  2)  indicates  the  lower 
boundary  of  the  middle  cranial  fossa,  and  the  removal  of 
bone  above  it  to  any  considerable  extent  will  expose  the 
contents  of  the  cranial  cavity.  Therefore  in  the  mastoid 
operation  when  performed  for  the  relief  of  acute  mastoid 
suppuration,  the  chiseling  or  other  means  used  to  re- 
move the  bony  cortex  should  be  carried  on  entirely 
below  this  ridge.  In  case  the  ridge  cannot  be  made 
out,  owing  to  its  lack  of  development,  the  superior 
meatal  margin  must  be  taken  as  a  guide,  and  an 
imaginary  line  drawn  backward  and  slightly  upward 
from  it  will  serve  the  same  useful  purpose  as  the 
ridge  itself. 

The  suprameatal  triangle  (Fig.  165,  3),  lies  just  below  the  posterior 
zygomatic  ridge  and  immediately  behind  the  upper  margin  of  the  external 
auditory  meatus.  Since  this  triangle  forms  the  outer  wall  of  the  mastoid 
antrum  its  importance  as  a  guide  to  the  exposure  of  this  cavity  is  of  first 
value.  Macewen,  who  first  described  this  triangle  and  established  its  sur- 
gical importance,  gives  the  following  description  of  its  boundaries:  "The 
base  is  formed  by  the  posterior  root  of  the  zygoma  running  somewhat 
horizontally  above;  the  portion  of  the  descending  plate  of  the  squamous, 
which  forms  the  arch  of  the  osseous  part  of  the  external  auditory  meatus 
below,  and  a  base  line  uniting  the  two,  dropped  from  the  former  on  a 
level  with  the  posterior  border  of  the  external  auditory  meatus."1  It 
will  thus  be  seen  that  this  triangle  is  not  wholly  bounded  by  visible  land- 
marks, and  many  times  no  marks  at  all  are  present  except  the  supero- 
posterior  meatal  margin.  However,  when  the  flaps  of  overlying  soft 
tissue  are  widely  dissected,  exposing  the  osseous  surface  of  the  mastoid 

1  Dis.  oj  Brain  and  Spinal  Cord,  p.  9. 


FIG.   164. — DRESS- 
ING-FORCEPS. 


THE   MASTOID   OPERATION    FOR   ACUTE   MASTOIDITIS 


297 


process  extensively  and  the  wound  is  free  from  blood,  the  experienced 
operator  will  at  a  glance  map  out  the  region  of  this  triangle  with  sufficient 
accuracy  for  operative  purposes,  even  though  all  the  landmarks  are 
poorly  denned.  The  beginner  will  obtain  a  better  knowledge  of  this 
triangle  from  a  study  of  Fig.  165,  which  was  made  from  a  specimen  on 
which  these  landmarks  are  clearly  visible,  than  can  be  obtained  from  a 
study  of  the  temporal  bone  itself,  especially  should  the  lines  on  its  surface 
be  but  poorly  developed. 

Upon  the  surface  of  this  triangle,  and  immediately  posterior  to  the 
upper  part  of  the  postmeatal  margin,  are  seen  the  suprameatal  fossa 


FIG.  165. — RIGHT  TEMPORAL  BONE  ox  WHICH  THE  LANDMARKS  ARE  VERY  WELL  DEVELOPED. 
1,2,  linea  temporalis ;  3,  suprameatal  triangle ;  4,  course  of  sigmoid  sinus.     Note  the  unusal  length  of  styloid 

process. 

and  spine  (see  Fig.  8).  These  external  markings  are  not  present  in 
some  cases,  but  in  others  are  so  well  developed  that  the  spine  is  quite 
prominent,  and  the  fossa  is  sufficiently  large  to  accommodate  the  ball  of 
a  small  finger. 

The  mastoid  process  may  be  found  broad  or  narrow.  If  broad,  the 
fact  is  probably  indicative  of  a  normal  situation  of  the  sigmoid  sinus, 
middle  cranial  fossa,  and  facial  nerve;  whereas  a  narrow,  thin  process 
is  suggestive  of  a  crowded  condition  of  these  important  structures,  and 
serves  as  a  warning  to  the  operator  that  unusual  care  must  be  observed 
in  order  to  avoid  wounding  one  or  more  of  them  during  the  operation. 


298 


THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


Opening  the  Mastoid  Antrum. — Since  no  mastoid  operation  can 
be  considered  good  surgery  in  which  the  antrum  has  not  been  entered, 
and  since  when  this  cavity  is  once  exposed  it  furnishes  the  best  guide  for 
the  extension  of  the  wound  in  any  necessary  direction,  it  should  be  the 
aim  of  the  surgeon  to  open  the  antrum  as  the  first  step  of  the  bone  abla- 
tion. To  accomplish  the  removal  of  the  bony  cortex,  as  well  as  the 
denser  portions  of  the  mastoid  interior,  the  author  recommends  the 

employment  of  chisels  and  gouges 
as  both  efficient  and  rapid,  since 
either  of  these  instruments  is  safer 
than  the  various  drills  and  burrs 
which  are  propelled  by  a  dental  en- 
gine. Several  chisels  and  gouges  of 
different  sizes  (see  Figs.  167  to  172) 
should  be  at  hand.  These,  as  well  as 
every  other  cutting  tool  that  is  to 
be  used,  should  in  every  case  be  as 


FIG.  166. — FIBER  MALLET. 


FIG.  167. — MASTOID  GOUGE. 


sharp  as  the  grinder's  art  can  provide,  since  dull  instruments  not  only 
retard  the  progress  of  the  operation,  but  also  necessitate  heavier  strokes  of 
the  mallet  (Fig.  166)  in  the  cutting  than  should,  for  obvious  reasons,  be 
employed  when  operating  on  the  cranium.  The  largest  chisel  or  gouge 
(Fig.  167)  is  selected  for  removing  the  cortex.  Its  cutting  edge  is  placed 
against  the  bone  just  posterior  to  the  suprameatal  fossa  if  this  landmark 
is  present,  or  about  the  center:  of  the  suprameatal  triangle  if  this  latter 


THE   MASTOID    OPERATION    FOR   ACUTE   MASTOIDITIS  299 

area  be  taken  as  the  guide  (Fig.  168).  The  cutting  operations  must  be 
conducted  throughout  with  the  chisel  directed  at  all  times  toward  the 
auditory  meatus.  The  reason  for  beginning  the  chiseling  so  near  the 
posterior  rim  of  the  auditory  meatus  is  that  by  this  precaution  only  can 
the  operator  avoid  wounding  the  sigmoid  sinus,  should  this  vessel  run 
abnormally  far  forward,  as  shown  in  Fig.  182.  Thin  slices  of  the  bone 
are  rapidly  removed,  the  operator  noting  the  nature  of  the  underlying 
structure  before  making  each  cut,  he  being  thus  able  to  recognize  the 
wrall  of  the  sigmoid  sinus  or  the  dura  of  the  middle  fossa  should  either 
be  accidentally  uncovered.  Frequent  drying  of  the  wound  by  means 


FIG.  168. — CASE  OF  RUPTURE  THROUGH  MASTOID  CORTEX  NEAR  SITE  OF  ANTRUM. 
Gouge  shown  in  position  of  safety  to  begin  removal  of  cortex.     The  gouge  may,  if  desired,  be  pointed  in 
any  other  direction  toward  the  auditory  canal.     When  the  osseous  structure  surrounding  the  point  of  rupture 
is  softened  by  the  disease,  the  use  of  a  sharp  curet  is  often  preferable  to  the  gouge  or  chisel. 

of  the  gauze  sponges  and  the  removal  of  the  bony  chips  as  rapidly  as 
they  are  cut  away  are  necessary  to  safe  operating.  As  the  osseous 
cavity  is  by  this  means  deepened,  it  becomes  necessary  to  work  with  a 
smaller  chisel  (Figs.  169  to  172  and  Fig.  242).  If  the  cellular  structure 
of  the  bone  is  found  sufficiently  soft,  either  naturally  or  as  a  result  of 
the  mastoid  disease,  a  stout,  sharp  curet  or  scoop  (Fig.  243)  can  be  used 
to  good  effect,  and  often  the  greater  part  of  the  osseous  tissue  between 
the  cortex  and  antrum  can  by  this  means  be  rapidly  and  safely  removed. 
The  curet,  like  the  chisel,  should  always  be  driven  in  the  direction  of  the 
auditory  meatus.  When  the  usual  depth  of  the  antrum  is  approached, 


300 


THE    PRINCIPLES  AND    PRACTICE   OF   OTOLOGY 


a  bent  silver  probe  (see  Fig.  200)  or  the  explorer  (Fig.  173)  should 
be  inserted  into  any  cell  that  is  opened,  so  that  the  antrum  may  be 
recognized  at  the  earliest  moment.  It  often  becomes  necessary,  as  the 
wound  deepens,  to  enlarge  the  cortical  portion  of  the  mastoid  opening  in 
order  to  give  more  freedom  for  the  manipulation  of  the  instruments. 
This  can  safely  be  done  at  any  time  after  the  cone-shaped  opening  is 
well  begun,  provided  that  the  same  care  be  given  in  the  removal  of  each 
bony  chip  that  has  already  been  suggested.  It  often  happens  that  when 


FIG.  169. 


FIG.  170. 


FIG.  171. 


FIG.  172. 


FIG.  173. — ALLPORT'S 
EXPLORER. 


the  superficial  cells  are  reached  the  outer  table  of  bone  will  overhang 
them  in  such  manner  that  the  bone  forceps  (see  Fig.  269)  can  be  used 
rapidly  and  safely  in  the  removal  of  large  superficial  areas. 

When  the  antrum  is  entered  it  may  be  readily  recognized  both  by  its 
situation  and  large  size.  Its  walls  should  be  at  once  explored  (Fig.  174) 
in  all  directions  by  means  of  the  probe  in  order  to  determine  the  extent  of 
overhanging  bone  that  must  subsequently  be  removed.  To  accomplish 
this  removal,  the  chisel,  scoop,  and  forceps  may  be  used,  and  the  outer 


THE   MASTOID   OPERATION    FOR   ACUTE    MASTOIDITIS  301 

wall  of  the  cavity  cut  away  until  the  opening  into  the  antrum  thus 
provided  is  as  large  as  any  portion  of  the  antrum  itself.  To  test  this 
point  the  bent  explorer  is  inserted  to  the  bottom  of  the  antrum  at  any 
portion,  when  if  it  can  be  withdrawn  without  meeting  any  overhanging 
ledge,  it  may  be  considered  that  a  sufficient  amount  of  bone  has  been 
removed.  The  antrum  is  now  temporarily  packed  with  a  strip  of  gauze  to 
arrest  the  bleeding  in  this  portion  of  the  wound. 

The  mastoid  cells  are  next  attacked  if  the  previous  history  of  the 
case  and  the  present  inspection  of  this  portion  of  the  mastoid  indicates 
that  the  disease  has  extended  to  the  tip.  The  broadest  gouge  is  applied 
at  the  mastoid  tip,  and  with  the  edge  directed  upward  the  cortex  is 
rapidly  removed  by  a  few  strokes  of  the  mallet.  The  outer  portion  and 


FIG.  174. — SHOWING  THE  MASTOID  ANTRUM  PARTIALLY  OPENED,  THE  OPERATOR  ENTERING  THE  CAVITY 
WITH  THE  EXPLORER  FOR  THE  PURPOSE  OF  DETERMINING  ITS  SIZE  AND  THE  EXTENT  OF  THE  OVERHANGING 
OSSEOUS  LEDGES  WHICH  MUST  BE  REMOVED 

cellular  interior  of  the  tip  of  the  apophysis  should  be  entirely  removed 
in  many  cases.  The  cellular  interior  should  be  scooped  and  bitten 
away  until  the  bottom  of  the  entire  wound  in  every  direction  is  smooth 
and  free  from  pockets  or  suspicious  areas  of  diseased  bone.  The  ragged 
edges  of  the  cortex  at  the  mouth  of  the  bony  wound  must  also  be  smoothed, 
beveled,  and  honed  with  appropriate  instruments  until  a  strictly  surgical 
margin  is  everywhere  encountered. 


302  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

The  packing  which  was  a  few  moments  before  placed  into  the  mastoid 
antrum  is  now  removed  and  since  the  pressure  of  the  gauze  has  by  this 
time  arrested  the  bleeding,  the  walls  of  the  cavity  can  be  better  inspected 
than  before  and  any  remaining  portion  of  diseased  membrane  or  rough- 
ened bone  can  be  detected  and  removed.  When  the  antrum  has  been 
thoroughly  cleansed  of  disease,  a  small  sharp  curet,  bent  to  an  appro- 
priate curve  (Fig.  216,  D),  should  be  passed  through  the  aditus  ad 
antrum,  by  which  means  this  channel  is  very  gently  cureted  in  an  out- 
ward direction  and  a  free  communication  between  the  antrum  and  the 
middle  ear  is  thus  established.  Care  must,  of  course,  be  exercised  as  to 
the  distance  to  which  this  instrument  is  inserted  into  the  aditus,  since  if 
it  is  passed  too  far  in  the  direction  of  the  tympanic  cavity  this  latter 
space  will  be  entered,  injury  to  the  ossicles  or  membrana  tympani 
may  result,  and  unnecessary  damage  to  the  hearing  will  follow. 

The  posterior  root  of  the  zygoma,  which  overhangs  the  antrum  to 
a  greater  or  less  extent  in  many  cases,  sometimes  contains  several  cells 
that  are  also  apt  to  become  infected  in  any  case  of  mastoiditis  (see  Fig. 
1 8).  Before  the  mastoid  operation  can  be  considered  completed,  there- 
fore, the  operator  should  continue  the  removal  of  bone  in  this  direction 
in  order  to  determine  if  this  adjacent  portion  of  the  zygoma  is  solid  or 
pneumatic,  and  if  the  latter,  whether  or  not  the  cells  are  infected  and 
suppurating.  If  pus  is  found,  the  cortex  must  be  bitten  away  with 
forceps,  and  the  cellular  tissue  cureted  out  to  the  extent  that  this  portion 
of  the  wound  is  left  free  from  pockets  and  smooth  in  every  direction.  To 
accomplish  this  as  thoroughly  as  good  surgery  demands  requires  that 
the  primary  incision  of  the  soft  parts  be  extended  somewhat  forward 
above  the  ear  in  order  to  give  a  sufficiently  large  exposure  of  the  post- 
zygomatic  region. 

The  entire  wound  is  then  irrigated  with  hot  boric  or  saline  solution 
for  the  purpose  of  removing  any  loose  spicula  or  bony  chips  that  have 
previously  escaped  attention.  Following  this  procedure,  the  whole 
cavity  is  thoroughly  dried  with  gauze  mops,  after  which  every  portion  of 
the  bony  cavity  should  be  finally  inspected  to  make  sure  that  no  diseased 
area  or  roughened  surface  is  permitted  to  remain.  A  few  moments 
spent  at  this  stage  of  the  operation  in  smoothing  any  irregular  surface,  or 
in  removing  some  small  area  of  suspicious  looking  bone,  will  unquestion- 
ably shorten  the  time  required  for  healing,  or  even  obviate  the  necessity 
for  a  second  operation.  Perhaps  nowhere  in  surgery  is  judicious  care 
as  to  detail  in  the  respect  just  mentioned  more  amply  rewarded  by 
successful  results  than  in  the  mastoid  operation.  When  the  osseous 
wound  is  completed  it  has  the  appearance  shown  in  Fig.  175. 


THE   MASTOID    OPERATION    FOR   ACUTE    MASTOIDITIS 


303 


During  this  final  inspection,  or  at  any  previous  examination  of  the 
posterior  or  superior  walls  of  the  mastoid  antrum,  it  may  be  discovered 
that  a  fistulous  tract  leads  into  the  middle  fossa  of  the  skull  above,  or  into 
the  sigmoid  groove  posteriorly,  exposing  the  dura  of  the  cerebrum  to 
infection  in  the  one  instance  and  the  lateral  sinus  and  cerebellum  in  the 
other.  In  case  granulation  tissue  or  plastic  lymph  is  found  covering 
the  exposed  sinus  or  dura,  it  is  not  wise  to  remove  the  same  by  curet- 


\ 


FIG.  175. — THE  MASTOID  OPERATION  COMPLETED. 

The  bottom  of  the  mastoid  antrum  is  seen  in  the  upper  and  anterior  portion  of  the  osseous  wound.  On 
the  posterior  wall  the  thin  bony  covering  of  the  sigmoid  sinus  projects  into  the  opening.  The  method  of  using 
Allport's  retractors  is  shown.  It  should  be  remembered  that  the  shape  and  extent  of  the  osseous  wound  of 
no  two  mastoid  operations  are  exactly  the  same.  The  above  illustration  shows  only  a  completed  operation 
in  this  particular  case. 

ment  unless  it  is  proposed  to  open  the  sinus  immediately  afterward,  for 
the  reason  that  such  granulation  tissue  or  plastic  lymph  forms  nature's 
most  effective  barrier  to  the  entrance  of  pathogenic  bacteria  from  ad- 
joining sources.  This  form  of  protection  is  quite  analogous  to  that 
which  is  provided  for  the  bowels  during  septic  peritonitis.  The 
abdominal  surgeon  formerly  wiped  this  barrier  away  during  abdominal 
operations  with  a  resulting  high  mortality.  Now  he  allows  it  to  remain 


3°4 


THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


undisturbed,  greatly  to  the  betterment  of  his  statistics.     The  otologist 
may  wisely  follow  the  safer  practise  of  the  gynecologist  in  this  respect. 

Packing  the  wound  with  gauze  constitutes  the  next  step.1  Although 
every  suppurative  tissue  of  the  mastoid  has  been  thoroughly  obliterated, 
suppuration  within  the  middle  ear  continues,  and  now  finding  the  easiest 
exit  through  the  aditus  ad  antrum,  it  naturally  enters  the  mastoid  wound. 


FIG.  176. — INSERTING  THE  GAUZE  PACKING. 

The  distal  end  of  the  strip  should  be  inserted  to  the  bottom  of  the  antrum  and  against  the  aditus  ad  antrum. 
Folds  of  the  gauze  are  then  loosely  packed,  one  over  the  other,  until  the  whole  wound  is  loosely  filled. 

For  the  purpose  of  favoring  the  discharge  of  pus  from  the  middle  ear 
through  the  channel  of  the  aditus,  and  thus  preserving  the  function  of 
the  tympanic  cavity,  the  strip  of  gauze  packing  is  first  inserted  to  the 

1  Instead  of  packing  the  wound  with  gauze,  several  operators,  notably  Blake,  Reik, 
and  Sprague,  have  advocated  and  practised  the  method  of  allowing  the  wound  to  fill  with 
a  blood-clot,  which,  through  subsequent  organization  of  the  clot,  brings  about  a  much 
more  speedy  closure  of  the  mastoid  cavity.  The  blood-clot  dressing,  as  this  method  has 
been  called,  would  be  ideal  were  it  not  for  the  fact  that  in  the  acute  mastoid  case  the 
wound  which  is  to  be  filled  and  healed  by  the  clot  is  a  septic  one,  and  one  which,  because 
of  the  coincident  suppuration  in  the  tympanic  cavity,  cannot  be  rendered  absolutely  sterile. 
The  blood-clot  dressing  therefore  usually  becomes  speedily  infected,  breaks  down  and  is 
discharged.  Jack  reports  that  of  60  cases  treated  at  the  Massachusetts  Charitable 
Eye  and  Ear  Infirmary  by  the  blood-clot  dressing  that  the  clot  broke  down  in  48 
cases,  and  that  uncomplicated  healing  occurred  in  only  4  of  the  60  cases.  By  this 
method  the  accompanying  aural  discharge  is  not  so  favorably  affected,  and  this  constitutes 
another  and  a  most  excellent  reason  for  using  the  gauze  packing  rather  than  the  blood- 
clot  dressing. 


THE   MASTOID    OPERATION    FOR    ACUTE    MASTOIDITIS 


305 


bottom  of  the  antrum  (Fig.  176)  and  against  the  antral  mouth  of  the 
aditus.  Folds  of  the  strip  are  packed  over  each  other  with  moderate 
firmness  until  first  the  antrum  and  finally  the  entire  mastoid  excavation 
is  filled  with  the  gauze  to  the  level  of  the  skin  flaps  (Fig.  177). 

A  word  concerning  the  gauze  strip  which  is  to  be  used  for  packing 
the  mastoid  wound  will  be  of  service  to  the  beginner.  It  should  be 
somewhat  firmly  woven  with  selvage  edge,  18  to  24  inches  long  and 
|  inch  wide.  In  simple  mastoid  cases  the  strip  may  be  only  plain 
sterile  gauze,  but  if  the  mastoid  has  been  the  seat  of  a  violent  sup- 
puration, or  if  the  dura  of  the  sigmoid  sinus  or  middle  cranial  fossa  has 


FIG.  177. — THE  MASTOID  WOUND  PACKED  AND  THE  FLAPS  SUTURED  DOWN  TO  THE  LINEA  TEMPORALIS. 

The  illustration  gives  an  impression  that  the  gauze  is  tightly  crowded  into  the  wound.    The  packing  should 

in  reality  always  be  lightly  inserted. 

been  either  accidentally  or  intentionally  exposed  or  wounded  during  the 
operation,  a  5  per  cent,  saturation  of  the  gauze  with  iodoform  should  be 
used  for  the  first  dressing,  but  afterward  borated  gauze  may  be  substi- 
tuted. Before  inserting  the  strip  into  the  cavity  it  should  be  scrutinized 
carefully  to  determine  if  its  edges  or  ends  (Fig.  178),  carry  any  loose 
threads;  and  should  this  be  the  case,  to  remove  them  for  the  reason  that 
if  such  be  carried  into  the  wound,  they  are  apt  to  be  caught  in  the  granu- 
lations or  upon  the  bony  surface,  where  they  are  retained,  and,  escaping 
the  subsequent  attention  of  the  surgeon,  act  as  foreign  bodies  to  delay 
or  even  prevent  healing. 

That  portion  of  the  wound  through  the  soft  tissues  which  lies  above 
20 


306  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

the  temporal  ridge  should  not  be  packed.  The  periosteum  of  both  the 
anterior  and  posterior  flaps  should  be  seized  with  tissue  forceps,  drawn 
out  to  a  level  with  the  skin,  and  two  or  three  sutures  of  catgut  should  be 
so  accurately  passed  through  both  integument  and  periosteum  that  a 
perfect  coaptation  of  this  portion  of  the  flaps  is  obtained  and  a  union  by 
first  intention  will  result  (see  Fig.  177). 

The  balance  of  the  opening  is  left  unsutured.  Experience  has 
taught  that  the  broadly  open  wound  is  not  only  more  easily  and  pain- 
lessly dressed,  but  that  it  is  also  much  more  certain  to  finally  heal  com- 
pletely, for  the  reason  that  inspection  of  the  progress  of  the  healing  is  at 


FIG.  178. — FRAGMENTS  OF  GAUZE  REPRESENTING   PROPER  AND    IMPROPER  PREPARATION  FOR  INSERTION 

INTO  THE  MASTOID  WOUND. 
The  loose  ravelings  shown  in  one  would  be  detached  in  the  granulating  wound  and  cause  delay  in  healing. 

all  times  easy,  and  therefore  early  measures  can  be  taken  to  correct  any 
questionable  tendency  to  repair  that  may  arise. 

The  gauze  strip  that  was  inserted  into  the  external  auditory  meatus 
before  the  beginning  of  the  operation  is  now  removed  and  a  fresh  one 
is  inserted  to  the  bottom  of  the  canal.  It  is  essential  to  pack  this  with 
some  firmness  against  the  outer  end  of  the  posterior  wall  of  the  meatus 
for  the  reason  that  during  the  dissection  of  the  anterior  flap,  during  that 
part  of  the  operation  in  which  the  flaps  were  formed,  the  skin  and  peri- 
osteum of  this  portion  of  the  posterior  meatal  wall  were  separated  from 
the  underlying  bone,  and  if  the  two  are  not  now  pressed  together  snugly, 


THE    MASTOID   OPERATION    FOR   ACUTE   MASTOIDITIS  307 

sagging  of  this  wall  may  subsequently  occur  to  such  an  extent  as  to 
lessen  or  obliterate  the  lumen  of  the  external  auditory  canal. 

After  the  mastoid  wound  has  been  completed  and  packed,  it  is  the 
practise  of  some  operators  to  incise  the  drum  membrane  freely  before 
inserting  the  gauze  wick  into  the  external  auditory  meatus,  as  just 
described.  Such  an  incision  is  always  indicated  in  cases  in  which,  for 
any  reason,  the  mastoid  antrum  has  not  been  entered  during  the  mastoid 
operation.  While  no  harm  can  result  from  the  free  incision  of  the  drum 
membrane,  such  an  incision  is  scarcely  necessary,  provided  both  antrum 
and  aditus  ad  antrum  have  been  as  freely  opened  during  the  mastoid 
operation  as  has  been  advised  by  the  author,  because  under  such  circum- 
stances the  subsequent  formation  of  pus  in  the  tympanic  cavity  will 
find  a  perfectly  free  outlet  through  the  mastoid  wound,  and  the  discharge 
from  the  middle  ear  will,  as  already  stated,  rapidly  cease. 

Boric  acid  powder,  because  of  its  mildly  antiseptic  and  detergent 
qualities,  is  dusted  freely  over  the  edges  of  the  mastoid  wound;  loose 
gauze  is  placed  liberally  over  and  around  the  auricle,  and  the  dressing 
is  completed  by  an  accurately  applied  roller  bandage.  Some  caution  is 
necessary  in  arranging  the  gauze  behind  and  around  the  external  ear, 
and  in  the  application  of  the  roller  bandage,  to  avoid  kinking  the  pinna 
to  such  an  extent  as  to  produce  great  discomfort  or  even  unbearable 
pain  until  the  first  dressing  is  removed  and  the  error  is  corrected.  The 
completed  dressing  is  shown  in  Fig.  255. 

As  a  rule  but  little  shock  follows  this  operation.  The  subsequent 
pain  is  only  occasionally  severe  enough  to  require  the  administration  of 
an  anodyne.  Severe  pain  within  the  first  twenty-four  hours  is  some- 
times due  to  a  faulty  dressing.  After  this  time  it  will  more  likely  arise 
as  a  result  of  infection  of  the  skin  flaps  and  the  consequent  swelling  and 
tension  upon  the  sutures.  Soreness  and  stiffness  of  the  muscles  of  the 
neck  of  the  operated  side  is  a  natural  consequence  in  those  cases  in  which 
it  has  been  necessary  to  partially  or  entirely  separate  the  muscular 
attachments  from  the  mastoid  tip,  but  in  most  instances  this  symptom 
rapidly  disappears. 

The  postoperative  temperature  seldom  rises  above  100°  F.  If  it 
was  high  preceding  the  operation  it  usually  falls  almost  immediately  to 
the  normal  or  near  the  normal.  Any  marked  postoperative  rise,  coin- 
cident with  an  increase  of  pain,  is  commonly  indicative  of  a  stitch  or  flap 
infection,  and  usually  subsides  promptly  after  a  change  of  the  dressing 
and  the  correction  of  the  fault. 

The  length  of  time  the  first  dressing  should  be  allowed  to  remain 
undisturbed  varies  with  the  symptoms  which  arise.  If  the  temperature 


308  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

remains  normal  or  is  but  little  elevated,  if  the  pain  is  slight  or  entirely 
absent,  and  if  the  gauze  coverings  remain  dry  and  free  from  odor,  a 
change  of  dressing  is  not  indicated  earlier  than  the  fifth  or  sixth  day  after 
the  operation.  Should  the  patient  complain  of  pain  in  the  wound  during 
the  first  twenty-four  hours  an  anodyne  in  the  form  of  codein  or  morphin 
hypodermicaUy  may  be  given.  Persistence  of  the  pain  for  a  longer 
period  would  dictate  the  removal  of  the  outer  coverings  and  an  inspection 
of  the  condition  of  the  auricle,  skin  flaps,  and  sutures.  Saturation  of  the 
dressings  with  exudate  or  blood,  with  the  result  of  rendering  them  foul 
smelling  or  uncomfortably  stiff,  is  an  indication  for  earlier  change. 
During  this  time  the  patient  himself  is  treated  surgically  and  is  kept 
quiet  in  bed  on  a  restricted  diet.  The  bowels  should  be  moved  on  the 
third  or  fourth  day.  If  the  previous  prostration  of  the  patient  has  been 
marked,  extra  care  must  be  exercised  in  the  selection  of  a  most  nourishing 
diet,  in  addition  to  which,  benefit  is  often  obtained  from  the  early  admin- 
istration of  elixir  of  iron,  quinin,  and  strychnin,  or  some  other  equally 
efficient  tonic. 

The  first  change  of  dressing  is  painful  unless  the  physician  is  gentle 
in  every  manipulation.  In  the  typic  case  that  has  continued  without 
change  of  the  dressing  for  five  or  six  days  the  gauze  in  the  depth  of  the 
bony  wound  will  have  become  so  saturated  with  exudate  as  to  be  some- 
what slippery  and  therefore  easy  of  removal.  If  taken  out  at  an  earlier 
date  the  folds  of  gauze  are  often  somewhat  adherent  to  the  structures 
against  which  they  have  lain,  and  their  withdrawal  requires  more  effort, 
and  consequently  causes  more  pain.  When  all  are  removed  the  wound 
usually  appears  dry  and  granulations  are  seen  springing  from  almost  every 
point.  The  good  effects  of  the  mastoid  operation  on  the  suppurating 
middle  ear  may  be  judged  from  the  fact  that  the  gauze  wick  which  was 
inserted  into  the  external  meatus  at  the  time  of  the  operation,  when 
withdrawn  at  the  first  dressing  is  often  found  moist  only  at  the  inner  end, 
and  may  be  dry  throughout,  thus  demonstrating  the  fact  that  the  dis- 
charge from  the  middle  ear  has  either  ceased  or  that  it  has  found  exit 
through  the  mastoid  wound.  The  greatest  improvement  in  this  respect 
is  often  noted  in  cases  where,  previous  to  the  mastoid  operation,  the 
discharge  had  been  so  profuse  that  a  similar  gauze  wick  when  inserted 
into  the  meatus  would  have  been  saturated  with  pus  in  an  hour.  It  is 
seldom  necessary  to  irrigate  the  mastoid  wound  at  the  first  dressing. 
Any  collection  of  dried  secretion  or  blood  that  may  be  found  on  the 
adjoining  skin  or  edges  of  the  flaps  is  best  removed  by  gently  rubbing 
the  same  with  a  pledget  of  cotton  saturated  with  hydroyen  peroxid, 
and  held  in  the  jaws  of  a  dressing-forceps.  Any  slight  collection  of 


THE    MASTOID   OPERATION    FOR   ACUTE    MASTOIDITIS  309 

exudate  in  any  part  of  the  mastoid  opening  should  be  absorbed  by  means 
of  small  gauze  sponges  applied  directly  to  the  suppurating  area.  Anti- 
septic powder  may  or  may  not  be  dusted  into  the  wound,  according  to 
the  preference  of  the  surgeon  or  to  the  appearance  of  the  granulating 
surface.  If  used,  only  a  quantity  sufficient  to  lightly  cover  the  raw 
surfaces  should  be  employed.  A  fresh  gauze  strip  should  then  be 
inserted  into  the  mastoid  wound  and  a  separate  one  into  the  auditory 
canal,  exactly  as  at  the  primary  dressing,  and  the  roller  bandage  should 
be  again  applied. 

Subsequent  dressings  must  be  made  every  twenty-four  to  forty-eight 
hours,  depending  largely  upon  the  rapidity  with  which  the  gauze  cover- 
ings are  soiled.  When  the  granulating  process  becomes  active,  the 
secretion  may  become  correspondingly  profuse,  in  which  case  irrigation 
is  properly  performed  each  time.  For  this  latter  purpose  a  saturated 
solution  of  boric  acid  or  the  normal  salt  solution  is  sufficient.  It  is 
not  advisable  to  irrigate  the  external  auditory  meatus  at  any  time  sub- 
sequent to  the  mastoid  operation,  provided  the  discharge  through  this 
channel  has  ceased  or  is  only  slight. 

On  the  occasion  of  each  dressing  it  is  essential  that  the  surgeon  should 
carefully  scrutinize  every  portion  of  the  healing  surface  in  order  that  he 
may  be  able  to  detect  at  the  earliest  moment  any  area  of  bone  that 
fails  to  be  covered  by  healthy  granulations,  for  it  sometimes  happens 
that,  following  an  operation  in  which  the  destructive  disease  of  the  bone 
has  been  violent,  additional  death  of  osseous  tissue  may  subsequently 
occur,  even  though  at  the  time  of  the  operation  every  suspicious  area 
had  been  thoroughly  removed.  Should  such  an  occurrence  take  place, 
granulations  will  fail  to  form  over  the  necrosing  areas  or,  having  once 
formed,  will  soon  become  sufficiently  luxuriant  to  conceal  the  area  of 
dead  bone.  If  extension  of  the  necrotic  process  be  recognized  sufficiently 
early,  and  its  surface  be  vigorously  cureted  at  this  time,  healthy  granu- 
lations may  thus  be  stimulated  and  the  part  may  be  sufficiently  covered 
to  preserve  its  life.  Should  it  not  do  so  and  should  separation  of  the 
bone  occur,  the  resulting  sequestrum  is  felt  with  the  probe  under  the 
semipolypoid  mass  of  granulations  and  should  be  entirely  removed. 

The  open  wound  must  heal  by  filling  in  with  granulations  from  the 
bottom  and  sides.  The  unsutured  portion  of  the  skin  flaps  should, 
therefore,  be  kept  widely  separated  by  means  of  the  gauze  packing.  If 
the  external  portion  of  the  wound  is  allowed  to  close  too  rapidly  there 
will  likely  result  a  fistulous  tract  leading  to  a  more  or  less  diseased  cavity 
within.  It  is  from  this  cause  that  secondary  operations  are  frequently 
necessary.  The  granulations  when  healthy  are  always  small  and  firm. 


310  THE   PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 

Large  and  flabby  granulations  are  pathologic  and  require  removal  by 
the  curet  or  caustic.  A  bead  of  silver  nitrate  fused  on  the  end  of  a 
probe  (see  Fig.  132)  furnishes  an  excellent  means  of  destroying  the  dis- 
eased granulations  without  risk  of  injury  to  adjacent  healthy  structures. 

It  will  be  seen  that  a  successful  termination  of  the  operated  cases 
depends  in  no  small  measure  upon  the  amount  of  painstaking  care  the 
surgeon  devotes  to  the  after-treatment.  It  is  always  desirable,  therefore, 
that  the  patient  remain  until  well  under  the  immediate  observation  of 
the  operator  or  his  trained  assistant. 

The  length  of  time  required  for  the  complete  healing  of  the  wound 
varies  greatly.  Some  cases  are  well  within  a  month,  while  others  require 
a  much  longer  time.  After  a  week,  many  times  earlier,  the  patient  may 
sit  up  in  a  chair  and  be  permitted  to  walk  about  his  room.  After  ten 
days  or  two  weeks  the  average  patient  may  leave  the  hospital,  and 
subsequent  attention  may  be  given  at  the  surgeon's  office.  Postaural 
deformity  of  any  consequence  results  only  in  the  worst  cases — those  in 
which,  in  order  to  do  a  successful  operation,  it  becomes  necessary  to 
remove  a  large  amount  of  bone,  and  also  in  that  class  where  the  patient 
is  old  or  decrepit,  and  in  which  granulation  takes  place  with  such  slow- 
ness that  the  skin  covers  the  depression  before  the  granulation  tissue 
fills  the  cavity  of  the  wound  sufficiently  to  reach  the  skin  level.  The 
scar  usually  resulting  from  the  operation  for  acute  mastoiditis  is  so  slight 
that  it  amounts  to  nothing  more  than  the  line  indicating  the  union  of 
the  flaps,  and  this,  because  of  its  hidden  position  behind  the  auricle,  is 
not  commonly  observed. 

BEZOLD'S  ABSCESS 

The  name  has  been  given  to  a  collection  of  pus  in  the  tissues  of  the 
neck  that  has  resulted  from  the  rupture  of  a  mastoid  abscess  into  the 
digastric  fossa  (Fig.  179),  from  whence  the  pus  finds  its  way  down  the 
neck.  Reference  to  Figs.  152  and  252  will  explain  the  ease  with  which 
Bezold's  abscess  may  take  place  during  a  mastoid  suppuration,  provided 
the  structure  of  the  mastoid  process  is  of  the  large  cellular  type.  Bezold's 
abscess  is  quite  likely  to  occur  in  any  case  in  which  a  large  cell  exists 
at  the  tip  of  the  process,  especially  when  the  cortex  of  this  cell  is  exceed- 
ingly thin,  as  in  the  specimens  shown  in  Figs.  152  and  232.  It  is 
entirely  improbable  that  such  an  abscess  ever  occurs  in  cases  of  which 
Fig.  153  is  a  type.  Since  the  purulent  material  is  discharged  from 
the  mastoid  process  into  the  cellular  tissues  of  the  neck  at  a  point 
beneath  the  deep  cervical  fascia,  its  natural  tendency  is  to  subsequently 
dissect  its  way  downward  along  the  cervical  vessels,  nerves,  and  muscles, 


THE    MASTOID   OPERATION    FOR   ACUTE    MASTOIDITIS 


and  in  this  way  it  has  been  known  to  reach  the  thorax.  In  any  case 
of  discharging  ear  that  is  complicated  by  mastoid  inflammation,  if  a 
hard  and  painful  swelling  should  occur  below  the  tip  of  the  mastoid  proc- 
ess (Fig.  1 80),  together  perhaps  with  increased  temperature  and  rigor, 
infection  of  the  cervical  tissues  in  the  manner  just  described  should  be 
suspected.  Owing  to  the  great  depth  of  this  accumulation  of  pus  and 
the  tension  of  the  intervening  tissues,  fluctuation  is  not  present,  at  least 
not  as  an  early  symptom.  In  order  to  prevent  the  dangers  resulting 
from  the  migration  and  dissemination  of  the  pus  after  it  has  broken 
through  the  mastoid  cortex  the  condition  should  be  detected  at  the 
earliest  possible  moment,  in  order  that  correct  surgical  measures  may  at 
once  be  instituted  for  its  removal.  Local  applications  in  the  form  of 


Middle  cranial 
fossa 


Carious  tract  with 
rupture  into  di- 
gastric fossa 


Carious  area 


Small  carious  area 
Condylar  foramen 


FIG.  179. — NECROSIS  OF  MASTOID  WITH  RUPTURE  INTO  THE  DIGASTRIC  FOSSA  (BEZOLD'S  ABSCESS)  AND 

ALSO  INTO  THE  MIDDLE  CRANIAL  FOSSA. 

This  most  interesting  and  instructive  specimen  shows  the  direct  course  of  the  necrosis  from  the  mastoid 
interior  through  the  cellular  structure  which  is  completely  broken  down,  to  the  digastric  groove  in  one  direction 
and  to  the  cranial  cavity  in  the  other. 

(Specimen  of  J.  Orne  Greene,  Warren  Medical  Museum,  Harvard  Medical  School.) 

liniments  or  poultices  should  have  absolutely  no  place  in  the  treatment. 
That  the  abscess  is  present  in  any  case  is  only  proof  that  the  mastoid 
operation  has  been  already  too  long  delayed  and  that  it  is  now  urgently 
indicated.  In  such  cases  the  deep  abscess  in  the  neck  is  operated  on  at  the 
same  time  and  as  a  necessary  part  of  the  mastoid  operation.  The  mastoid 
should  be  thoroughly  opened  and  the  tip  completely  removed,  as  has 
been  fully  described  above.  Following  this  a  director  or,  preferably,  the 
finger  of  the  operator,  is  inserted  into  the  abscess  cavity  at  the  bottom 
of  the  mastoid  wound,  and  the  tissues  are  by  that  means  dissected  along 


312  THE    PRINCIPLES   AND   PRACTICE    OF   OTOLOGY 

the  tract  of  the  abscess,  to  its  lowermost  position  in  the  neck.  At  this 
latter  point  the  intervening  structures  between  the  skin  and  finger-tip 
should  be  freely  incised,  and  a  counteropening  sufficiently  large  to 
permit  free  drainage  be  thus  established.  A  strip  of  gauze  is  then 
inserted  from  above,  through  the  passage  made  by  the  finger,  and  this 
is  brought  out  through  the  lower  opening,  above  which  the  entire  cavity 
is  filled  with  the  gauze.  If  the  pus  is  foul  smelling  and  its  range  through 
the  neck  has  been  wide,  after  the  counterincision  is  made  through  the 


FIG.  180. — BEZOLD'S  ABSCESS. 

Compare  the  position  of  the  auricle  and  of  the  tumefaction  with  that  produced  by  rupture  through  the  mastoid 
cortex  over  the  site  of  the  antrum,  as  shown  in  Fig.  181. 

lowermost  portion,  it  will  be  advisable  to  thoroughly  irrigate  the  wound. 
Should  the  abscess  have  reached  a  point  beyond  the  middle  of  the  neck, 
or  perhaps  near  the  clavicle,  its  obliteration  will  be  most  certainly  and 
safely  accomplished  by  laying  the  tract  open  for  a  considerable  distance, 
and  then  packing  the  open  wound  with  gauze  until  healthy  granulations 
are  everywhere  established  and  the  wound  is  thus  filled  in  from  the 
bottom. 

SUBPERIOSTEAL  ABSCESS 

Subperiosteal  or  postaural  abscess  occurs  over  the  mastoid  region  as 
a  symptom  in  a  considerable  number  of  all  cases  of  acute  mastoiditis 
(Fig.  181).  While  it  is  most  commonly  observed  in  the  neglected  cases, 
yet  it  is  sometimes  seen  within  a  week  after  the  beginning  of  a  severe 
mastoid  complication.  In  adults  the  occurrence  of  such  an  abscess  is 
nearly  always  the  result  of  a  perforation  of  the  bone  caused  by  the 
rupture  of  the  abscess  externally  and  a  leakage  of  pus  through  to  the 


THE    MASTOID   OPERATION    FOR   ACUTE    MASTOIDITIS  313 

under  surface  of  the  periosteum  (see  point  of  rupture  in  Fig.  168), 
which  latter  is  everywhere  detached  in  the  directions  of  least  resist- 
ance. Since  the  attachment  of  the  periosteum  over  the  postauricular 
region  becomes  closer  as  it  approaches  the  tip  of  the  mastoid  proc- 
ess, where  the  muscles  are  inserted,  the  pus  in  these  cases  finds  an 
easier  passage  in  an  upward  and  backward  direction;  it  usually 
collects  posterior  to  and  somewhat  above  the  attachment  of  the  auricle, 
which  latter  is  thereby  pushed  outward  and  downward  to  the  extent  of 
giving  a  deformed  appearance  to  that  side  of  the  head.  This  form  of 
abscess  is  most  frequently  met  with  in  infants  and  young  children,  in 
which  cases  the  pus  may  escape  from  the  interior  to  the  surface  of  the 


FIG.  181. — PROJECTION  OF  THE  AURICLE  IN  MASTOIDITIS  WITH  POSTACRAL  ABSCESS. 
The  collection  of  pus  is  above  and  behind  the  auricular  attachment.     Compare  this  condition  with  that 
produced  by  a  rupture  of  pus  into  the  digastric  fossa  (see  Figs.  179  and  180).  Note  also  the  expression  indic- 
ative of  an  adenoid  which  was  a  causative  factor  in  the  production  of  the  aural  and  mastoid  affection. 

mastoid,  through  the  squamomastoid  suture  (Fig.  9),  which  exists  at 
this  period  of  life,  and  hence  in  this  class  of  patients  it  is  not  necessary  to 
presuppose  the  presence  of  a  bony  perforation. 

Since  a  subperiosteal  abscess  is  only  a  symptom  of  the  underlying 
osseous  suppuration,  the  treatment  of  any  case  thus  complicated  differs 
but  little  from  that  afforded  by  the  mastoid  operation  already  described. 
When  the  periosteum  has  been  separated  from  the  bone  for  a  period  of 
several  days  the  surface  of  the  latter  structure  is  sometimes  found  rough- 
ened and  grayish  in  color  over  the  denuded  area.  When  this  has 
occurred,  it  should  be  cureted  in  every  quarter  after  the  complete 
mastoid  operation  has  been  performed,  and  just  previously  to  suturing 


314  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

the  skin  flaps.  The  periosteum  itself  is  frequently  found  nccrotic  in 
places  or  covered  on  its  under  surface  by  unhealthy  granulations,  while 
the  soft  parts  covering  the  periosteum  itself  are  infiltrated  with  septic 
fluids.  When  so  diseased,  the  flaps  should  be  freely  dissected  from  the 
bone,  then  turned  outward  to  an  extent  that  widely  exposes  the  under 
surface  of  the  periosteum,  when,  if  found  granular  or  necrotic,  the  curet 
or  curved  scissors,  if  necessary,  is  vigorously  applied  and  the  diseased 
areas  are  completely  removed. 

Dangers  of  the  Mastoid  Operation. — The  dangers  which  may  be 
encountered  in  the  performance  of  the  mastoid  operation  are  injuries  (a) 
to  the  facial  nerve  with  resulting  facial  paralysis;  (b)  to  the  walls  of  the 
lateral  sinus,  causing  severe  hemorrhage;  and  (c)  to  the  dura  mater  above 
the  tegmen  antri,  with  resulting  exposure  of  the  cranial  contents  to  in- 
fection. In  cases  in  which  the  anatomic  relations  of  these  structures 
are  normal,  injury  to  any  of  them  is  not  probable,  provided  the  operator 
possesses  that  almost  perfect  knowledge  of  the  anatomy  of  the  parts  with- 
out which  the  operation  should  never  be  undertaken ;  provided  the  oper- 
ative landmarks  are  kept  in  mind  throughout  the  entire  procedure,  and  also 
provided  that  the  same  exceeding  care  which  should  always  characterize 
the  work  of  the  trained  and  experienced  surgeon  be  exercised  when  remov- 
ing the  tissues  adjoining  the  facial  nerve,  sigmoid  sinus,  or  brain  covering. 

Abnormalities  as  to  position  of  these  important  structures  may  be 
present  in  any  case,  and  when  this  is  true  the  possibility  of  injuring  one 
of  them  is  greatly  increased  even  though  the  greatest  care  be  exer- 
cised by  the  surgeon.  The  temporosphenoidal  lobe  of  the  cerebrum 
may  be  found  on  a  lower  level  than  the  ridge  of  the  posterior  root  of 
the  zygoma,  and  the  sigmoid  sinus  may  run  so  near  the  posterior  margin 
of  the  external  auditory  meatus  that  it  will  be  injured  even  when 
the  chiseling  is  performed  within  the  most  anterior  portion  of  the 
suprameatal  triangle  (Fig.  182).  It  has  already  been  stated  that  the 
width  of  the  mastoid  process  and  the  angle  which  the  auditory  meatus 
forms  with  the  surface  of  the  skull  furnish  some  information  concerning 
the  near  or  remote  situation  of  the  sigmoid  sinus  to  the  postmeatal 
margin;  nevertheless,  the  careful  operator  prefers  to  avoid  the  risk  of 
in  jury  to  so  large  a  vessel  by  following  the  advice  already  given — namely, 
to  make  the  initial  opening  into  the  bone  at  a  point  well  forward  in  the 
suprameatal  triangle,  to  at  all  times  direct  the  cutting  edge  of  the  chisel 
toward  the  external  meatus,  and  to  always  hold  the  chisel  at  such  an 
obtuse  angle  to  the  surface  of  bone  to  be  removed  that  it  is  possible  to 
remove  only  thin  chips  of  osseous  tissue  when  the  instrument  is  driven 
forward.  When  any  cell  or  space  of  whatever  nature  is  uncovered  on 


THE    MASTOID   OPERATION    FOR   ACUTE   MASTOIDITIS 


315 


either  the  upper  or  posterior  wall  or  in  the  bottom  of  the  wound,  the  same 
should  be  inspected  at  once  by  an  examination  with  an  exploring  in- 
strument in  order  to  learn  the  exact  nature  of  the  cavity  and  thus  to 
prepare  the  way  for  safely  removing  any  additional  portions  of  bone. 
In  the  acute  mastoid  operation  it  is  scarcely  possible  to  injure  the  facial 
nerve  unless  the  operator  invades  the  bone  recklessly  and  without  cor- 
rect anatomic  knowledge  or  experience  as  a  guide.  One  exception 
should  be  made  to  this  statement — namely,  that  the  mastoid  inflammation 
is  occasionally  of  such  violence  as  to  cause  the  death  of  a  considerable 
portion  of  the  process  en  masse.  In  such  instances  the  facial  nerve 


Mastoid  antrum 
Postmeatal  margin 

Knee  of  sigmoid  sinus 


FIG.  182. — CASE  IN  WHICH  THE  SIGMOID  SINUS  WAS  FOUND  ABNORMALLY  FAR  FORWARD. 
In  this  instance  the  vessel  lay  immediately  under  the  posterior  and  lower  part  of  the  suprameatal  triangle, 
(Fig.  165,  3)  and  would  have  been  opened  but  for  the  precaution  of  first  chiseling  away  the  anterior  portion 
of  the  triangle.     Xote  that  the  mastoid  antrum  is  small  and  crowded  far  forward. 

may  be  destroyed  by  the  disease  coincidentally  with  the  death  of  the 
surrounding  bone,  but  should  its  function  continue  for  a  time,  and 
should  the  mastoid  operation  be  then  performed,  the  nerve  would  in  all 
probability  be  unavoidably  injured.  The  wall  of  the  sigmoid  sinus 
may  be  wounded  by  any  of  the  instruments  used  in  the  performance 
of  the  mastoid  operation,  or  a  spicula  of  the  overlying  bone  may  be 
driven  into  it  in  the  efforts  of  the  operator  to  remove  the  diseased  osseous 
tissue  from  the  sigmoid  groove.  If  only  a  puncture  of  the  sinus  is  made, 
the  bleeding  from  the  vessel  will  be  profuse,  but  not  alarming,  whereas 
if  a  large  incision  or  tear  of  the  sinus  wall  is  made  the  resulting  hemor- 


316  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

rhage  is  severe,  persistent,  and  dangerous  unless  prompt  and  efficient 
measures  are  at  once  instituted  to  arrest  it.  In  case  one  of  the  more 
trivial  wounds  has  been  inflicted  upon  the  walls  of  the  vein  the  outpouring 
of  blood  is  at  once  so  considerable  as  to  obscure  the  entire  operative 
field  and  thus  to  stop  further  operating  until  the  bleeding  has  been 
arrested.  The  end  of  a  strip  of  gauze  J  inch  wide  should  be 
immediately  placed  over  the  site  of  the  injury,  and  over  this  a  strip  is 
folded,  forward  and  backward,  until  a  half  dozen  layers  have  been 
superimposed  upon  the  first,  when  the  ball  of  the  finger  of  an  assistant 
should  be  placed  firmly  upon  the  top  of  the  last  fold,  and  continuous 
pressure  be  exerted  until  the  flow  of  blood  has  ceased.  If  the  mastoid 
operation  were  well  under  way  before  the  injury  to  the  sinus  occurred, 
and  a  large  mastoid  opening  therefore  exists  in  the  bone,  it  will  be  en- 
tirely possible  to  proceed  with  the  operation  in  some  other  part  of  the 
field  while  waiting  for  the  fibrinous  sealing  of  the  wounded  vessel. 
After  a  few  minutes,  during  which  time  the  pressure  has  been  con- 
stantly exerted  upon  the  pressure  pad  which  covers  the  puncture  in  the 
sinus, the  gauze  pad  may  be  cautiously  removed,  when, if  bleeding  recurs, 
it  must  be  immediately  replaced.  In  most  cases  the  hemorrhage  will 
have  stopped  and  the  operation  may  proceed  as  though  no  accident  had 
occurred,  only  the  operator  and  assistants  must  use  great  care  not  to 
disturb  the  wounded  vessel  by  rude  manipulation  or  sponging  in  the 
immediate  vicinity  of  the  part. 

Should  the  sigmoid  sinus  be  extensively  incised  or  torn  during  the 
mastoid  operation,  it  becomes  imperative  to  at  once  check  the  bleeding. 
This  may  be  accomplished,  provided  the  sinus  wall  has  already  been 
widely  exposed  by  the  removal  of  its  osseous  covering  in  the  sigmoid 
groove,  by  quickly  turning  the  incised  edges  of  the  vessel  walls  into  the 
lumen  of  the  vein,  and  then  making  firm  pressure  upon  the  same  by 
means  of  a  properly  shaped  pad  of  sterile  gauze.  Should  this  plan  fail, 
it  may  become  necessary  to  insert  a  strip  of  sterile  or  medicated  gauze 
into  each  end  of  the  injured  vessel.  If  by  either  of  these  means  the 
bleeding  can  be  controlled,  the  operation  should  be  continued  until 
completed;  but  if  it  is  found  difficult  to  control,  and  the  pad  of  gauze, 
which  must  be  used  as  a  hemostat,  is  sufficiently  large  to  cover  the  field 
of  operation,  the  procedure  should  be  abandoned  for  a  period  of  one 
or  two  days. 

Injury  to  the  sinus  during  the  mastoid  operation  is  always  likely 
to  be  followed  by  sinus  infection  and  sinus  thrombosis.  This  result 
should  be  expected,  since  the  wound  of  the  vessel  exposes  its  contents 
directly  to  the  suppurating  mastoid  wound.  Of  course,  if  the  mastoid 


THE    MASTOID    OPERATION    FOR   ACUTE   MASTOIDITIS  317 

process  has  been  thoroughly  opened  and  cleaned  previously  to  the 
accidental  wounding  of  the  sinus  the  risk  of  infection  will  be  lessened, 
but  as  a  matter  of  fact  it  is  difficult  to  render  this  class  of  wound  sterile, 
and,  moreover,  the  instrument  which  causes  the  wound  is  of  necessity 
an  infected  one.  When  the  bleeding  has  been  controlled  after  such  an 
accident,  the  exposed  portion  of  the  sinus  wall  should  be  covered  with 
iodoform  gauze  while  the  operation  is  completed,  and  the  entire  wound 
is  as  completely  sterilized  as  possible.  A  fresh  strip  of  the  iodoform 
gauze  is  then  placed  over  the  sinus  so  as  to  form  a  pressure  pad  on  the 
site  of  the  wound  and  the  mastoid  dressing  is  completed  as  described  on 
p.  307.  A  separate  dressing  for  the  exposed  sinus  and  for  the  balance 
of  the  mastoid  wound  should,  if  possible,  be  maintained  at  each  subse- 
quent dressing  until  a  substantial  layer  of  healthy  granulation  has 
covered  and  protected  the  sinus.  In  case  an  infection  of  the  sinus  takes 
place  at  any  time,  symptoms  denoting  this  fact  will  quickly  arise  (see  p.  418). 
One  of  the  surest  means  of  guarding  against  the  accidents  and 
dangers  that  may  occur  during  the  performance  of  the  mastoid  opera- 
tion is  to  provide,  by  the  ample  dimensions  of  the  soft-tissue  flaps,  a  wide 
field  in  which  to  operate;  and  another  is  to  keep  this  field  so  thoroughly 
cleansed  from  blood  that  the  operator  may  at  all  times  clearly  see  the 
minutest  details  of  the  entire  surgical  area. 

MASTOIDITIS  IN  INFANTS 

Because  of  the  frequency  with  which  mastoiditis  in  infants  and  very 
young  children  is  met,  and  also  because  of  the  differences  that  arise  as 
to  its  cause  and  behavior,  as  compared  with  the  same  disease  when 
occurring  in  older  children  and  in  adults,  a  discussion  of  the  subject 
should  be  of  great  practical  value  to  the  student  and  practitioner. 

The  chief  differences  observable  in  this  class  of  patients  are  un- 
questionably due  to  the  developmental  state  of  the  temporal  bone  at 
birth  and  during  the  first  two  years  of  extra-uterine  life.  The  facts 
that  have  already  been  stated  concerning  the  development  of  the  temporal 
bone  have  a  bearing  upon  the  cases  which  is  of  such  practical  nature 
that  they  cannot  be  ignored,  because  frequently  neither  an  accurate 
diagnosis  of  mastoiditis  can  be  made  in  the  infant  nor  a  satisfactory 
treatment  instituted  unless  the  surgeon  is  familiar  with  the  rudimentary 
state  of  the  temporal  bone  at  this  early  period  of  life. 

It  is  a  clinical  fact  that  subperiosteal  mastoid  abscess  is  most  fre- 
quently seen  in  the  infant  and  very  young  child,  and  this  fact  is  readily 
accounted  for  by  the  persistence  of  the  squamomastoid  suture  at  this 
period  of  life  (Fig.  9).  The  plate  of  the  squamous  portion  of  the  tern- 


31 8  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

poral  bone  is  also  quite  thin,  sometimes  paper  thin,  and  the  mastoid 
antrum  lies  directly  under  it  without  any  intervening  cellular  tissue. 
In  short,  the  antrum  is  very  superficial,  necrosis  can  take  place  out- 
wardly with  ease,  and  hence,  in  some  cases  at  least,  the  very  superficial 
situation  of  the  antrum  itself  may  account  for  the  postaural  abscess. 

The  causation  of  mastoid  abscess  in  children  is  the  same  as  in  adults — 
namely,  infection  of  the  mastoid  antrum  through  the  channels  of  the 
Eustachian  tube  and  middle  ear.  The  frequency  of  the  occurrence  of 
acute  mastoiditis  in  infants  may  at  least  be  partially  accounted  for  on 
the  anatomic  reasons  that  the  Eustachian  tube  in  the  infant  is  propor- 
tionately much  wider  and  shorter  than  in  the  adult,  whereas  the  middle 
ear  and  mastoid  antrum  are  almost  as  large  as  they  ever  become, — 
anatomic  conditions  favoring  the  admission  of  disease  germs  from  the 
nasopharynx. 

The  symptoms  are  usually  not  so  well  marked  as  in  adults.  The 
first  indication  of  the  extension  of  the  suppurative  otitis  to  the  region 
of  the  mastoid  may  be  the  occurrence  of  the  postauricular  swelling. 
It  is  a  noteworthy  fact  that  infants  do  not,  as  a  rule,  appear  to  suffer 
great  pain  during  the  establishment  and  progress  of  this  disease.  It  is 
not  at  all  uncommon  to  meet  with  cases  in  which  the  postaural  abscess 
is  already  large,  and  yet  the  child  shows  few  if  any  evidences  of  acute 
suffering.  This  may  be  accounted  for,  first,  from  the  fact  that  the 
large  spaces  of  the  antrum  and  the  large  and  comparatively  short  Eus- 
tachian tube  permits,  in  addition  to  the  perforated  membrana  tympani, 
a  better  drainage  into  the  nasopharynx  than  is  possible  through  the 
same  channels  in  the  adult ;  and,  secondly,  by  the  ease  with  which  the 
pus  finds  its  way  outward  through  the  squamomastoid  fissure  which 
lies  inferior  to  the  antrum  and  marks  the  boundary  between  the  mastoid 
and  squamous  portions  of  the  bone  (Fig.  9).  Sometimes,  however, 
the  temperature  runs  high,  the  pain  is  severe,  exhaustion  is  evident, 
and  pulmonary  or  meningeal  symptoms,  that  lead  to  error  in  diagnosis 
and  treatment,  may  develop. 

Diagnosis. — Extension  of  the  suppuration  to  the  mastoid  antrum 
in  an  infant  should  be  suspected  in  any  case  that  has  been  preceded  by 
a  middle-ear  discharge,  which  does  not  promptly  cease  after  the  estab- 
lishment of  good  drainage,  and  in  which  anemia,  prostration,  continued 
fever,  or  malnutrition  become  evidence  of  some  complicating  ailment. 
Mastoid  tenderness  is  too  uncertain  to  be  helpful  in  many  cases  because 
an  infant  will  usually  cry  or  squirm  if  pressure  be  made  anywhere  on 
its  body.  Swelling  behind  and  above  the  ear,  when  occurring  in  con- 
nection with  an  aural  discharge,  is  the  most  certain  external  evidence 


THE    MASTOID   OPERATION   FOR   ACUTE   MASTOIDITIS  319 

of  the  mastoid  complication.  The  sagging  of  the  posterosuperior 
meatal  wall  at  its  junction  with  the  tympanic  ring,  which  is  frequently 
present  as  an  important  diagnostic  aid  in  adults,  when  occurring  in 
those  under  three  years  of  age  will  be  seen  upon  the  superior  instead 
of  the  superoposterior  wall  of  the  canal,  for  the  reason  that  there  are 
as  yet  no  cells  developed  in  the  mastoid  process  which  can  fill  with  pus 
and  cause  the  bulging  on  the  adjacent  posterior  wall.  The  mastoid 
antrum  and  attic  lie  almost  wholly  above  the  tympanic  ring,  and  hence 
collections  of  pus  within  these  spaces  would  affect  chiefly  the  superior 
meatal  wall.  The  treatment  directed  to  the  abortion  of  the  disease 
differs  in  no  essential  respect  from  that  already  advised  in  the  adult 
(see  p.  286).  The  surgical  treatment,  however,  must  be  greatly  modi- 
fied by  reason  of  the  anatomic  differences  that  exist  in  the  infantile  bone. 
The  Mastoid  Operation  as  Performed  on  Children  under  Two  Years 
of  Age. — Previous  to  this  age  there  is  commonly  no  development  of 
the  mastoid  process,  and  consequently  there  are  no  cells  to  be  opened 
and  no  mastoid  tip  to  be  removed.  There  is,  however,  present  at  birth 
the  one  large  cell,  the  mastoid  antrum,  and  it  is  with  this  single  cavity 
that  the  operator  must  deal  when  operating  on  the  infant  or  young 
child  for  mastoid  abscess.  To  open  this  cell  the  primary  incision  should 
begin  a  little  below  Reid's  base  line  (Fig.  269),  and  follow  the  post- 
auricular  attachment  at  the  usual  distance  to  a  point  above  and  posterior 
to  the  superior  attachment  of  the  auricle.  In  making  this  incision 
down  to  the  bone,  the  operator  should  not  forget  that  the  osseous  tissues 
of  the  skull  at  this  age  are  soft,  that  they  may  in  addition  be  necrotic, 
and  that,  therefore,  by  undue  pressure  upon  the  knife  it  is  easily  possible 
to  enter  the  cranial  cavity.  Instead  of  trying  to  make  one  incision  that 
will  extend  entirely  to  the  bone  throughout  the  entire  distance,  it  is 
much  safer  to  cut  through  the  skin,  fascia,  and  periosteum  by  separate 
and  careful  strokes  of  the  knife,  the  blade  of  which,  while  so  used,  should 
be  held  somewhat  away  from  the  perpendicular.  The  soft  parts  are 
then  reflected  in  the  usual  way  and  the  whole  osseous  field  of  operation  is 
exposed  to  view.  The  suprameatal  triangle  (see  Fig.  165,  3)  should  be 
sought  for  just  as  in  the  adult  case,  but  the  operator  must  remember 
that  the  position  of  this  is  changed  from  that  already  studied  in  the  fully 
developed  bone.  The  posterior  ridge  of  the  zygoma,  forming  the  linea 
temporalis,  lies  on  a  higher  plane  in  the  infant  and  must  be  sought  for 
at  a  greater  distance  above  the  superior  margin  of  the  tympanic  ring. 
It  is  not  well  developed  in  every  case  and  may  be  difficult  or  impossi- 
ble to  find,  but,  as  in  older  persons,  it  forms  the  superior  boundary  of 
the  triangle  and  indicates  the  uppermost  line  of  safety  in  operating. 


320  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

The  postero-inferior  border  of  the  triangle  is  formed  by  the  squamo- 
mastoid  suture,  which  can,  as  a  rule,  be  distinctly  traced  (see  Fig.  9). 
The  triangle  is  completed  by  the  antero-inferior  border  which  is  formed 
by  the  postero-superior  part  of  the  tympanic  ring  (see  Fig.  35).  The 
posterior  skin  flap  must  be  dissected  from  the  skull  for  a  sufficient 
distance  in  every  case  to  expose  the  squamomastoid  suture,  because 
this  marks  the  lower  limit  of  safety  in  the  operation. 

It  will  thus  be  seen  that  in  order  to  safely  open  the  mastoid  antrum 
of  an  infant  it  will  be  necessary  to  do  so  through  a  small  triangle,  which 
lies  in  a  higher  plane  than  the  suprameatal  triangle  of  the  adult;  and 
that  this  space  lies  more  nearly  above  than  behind  the  orifice  of  the 
external  meatus.  Any  attempt  to  enter  the  antrum  in  the  usual  way 
would  not  only  fail,  but  would  also  endanger  the  facial  nerve  which 
emerges  from  the  bone  as  high  up  as  the  line  drawn  horizontally  through 
the  center  of  the  external  auditory  meatus.  The  sigmoid  sinus  in  infants 
was  posterior  to  the  above  triangle  in  all  the  cases  examined,  and,  there- 
fore, if  the  operator  keeps  within  this  area  when  removing  the  bone  he 
will  run  slight  risk  of  injuring  this  vessel. 

Since  the  antrum  occupies  a  position  under  the  above  triangle,  it  is 
covered  only  by  the  very  thin  plate  of  the  squamous  portion  of  the 
temporal.  Hence,  to  expose  it  requires  but  a  few  gentle  strokes  of  the 
mallet  upon  the  small  sharp  gouge,  after  which  the  overhanging  ledges 
can  be  bitten  away  by  a  small  bone-forceps.  The  interior  of  the  cavity 
of  the  antrum  is  then  cureted  with  thoroughness,  but  with  the  exercise 
of  very  gentle  care.  The  after-treatment  varies  in  no  essential  particular 
from  that  already  advised  in  adult  cases  (see  p.  307). 


CHAPTER  XXVI 


THIS  disease,  because  of  its  frequency,  variety,  and  dangerous  com- 
plications, forms  one  of  the  largest,  most  interesting,  and  important 
chapters  in  otology.  It  is  highly  probable,  however,  that  when  the  pro- 
fession becomes  more  familiar  with  the  modern  principles  of  otologic 
practise  and  applies  the  same  more  vigorously  in  the  acute  stages  of 
aural  diseases  than  at  present,  the  number  of  cases  of  chronic  discharging 
ears,  together  with  the  numerous  and  serious  complications  of  the  same, 
will  be  greatly  diminished. 

Pathology. — In  chronic  suppurative  diseases  of  the  middle  ear 
the  suppurative  inflammation  attacks  the  mucous  membrane  of  the 
tympanum,  causing  polypoid  degeneration  with  the  formation  of  polypi 
or  cushions  of  granulomata.  The  inflammation  may  extend  to  the 
bone,  especially  in  tuberculosis  and  syphilis.  Acute  suppurative  otitis 
media  blends  into  the  chronic  disease  after  eight  weeks'  duration. 
This  rule  is  arbitrary,  for  there  is  no  sharp  division  between  acute  and 
chronic  suppurative  diseases.  Accompanying  the  granulomata  caries 
takes  place,  sometimes  necrosis  or  caries  necrotica.  Loss  of  the  incus 
is  common,  especially  its  short  process  and  head.  The  head  of  the 
malleus  or  its  handle  is  often  destroyed  and  such  changes  take  place 
as  are  described  under  caries  of  the  temporal  bone  (p.  550).  The  formation 
of  cholesteatomata  is  not  uncommon  and  the  bone  may  become  porous 
or  it  may  become  sclerotic,  even  ivory-like  (see  Fig.  241).  Destruction 
of  the  drum  membrane  may  be  slight  or  entire  (see  Figs.  196  and 
197).  Fig.  183  shows  a  section  of  drum  membrane  which  is  very 
much  thickened  and  opaque  as  a  result  of  chronic  aural  suppuration. 
The  mucous  membrane  epithelium  is  lacking  on  the  right  and  the 
drum  membrane  thins  down  to  scar  tissue  with  a  layer  of  mucous 
membrane  and  a  dermal  layer,  that  is,  the  membrana  propria  is  want- 
ing. In  this  figure  the  membrana  propria  is  not  clearly  defined.  The 
layer  of  mucous  membrane  is  greatly  thickened  with  areas  of  infiltra- 
tion and  enlarged  blood-vessels.  The  elastic  fibers  are  clearly  shown 

21  321 


322 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


in  each  of  the  three  layers  of  the  drum  membrane.  A  layer  of  des- 
quamated epithelium  nearly  the  thickness  of  the  thickened  drum  is 
adherent  to  the  dermal  layer.  The  discharge  may  be  mucopurulcnt, 
seropurulent,  thin,  and  acrid,  as  in  tuberculous  diseases;  very  thick 
and  stringy  when  the  Eustachian  tube  is  involved.  The  discharge  may 
be  very  abundant  or  very  slight,  sometimes  so  slight  as  to  form  crusts 
and  deceive  the  patient,  who  believes  the  ear  is  not  discharging.  The 
odor  is  sometimes  offensive.  Small  particles  of  bone  may  be  found  in 
the  discharge.  The  disease  may  end  in  any  of  the  so-called  complica- 
tions, such  as  brain  abscess,  meningitis,  sinus  thrombosis,  extradural 
abscess,  or  labyrinthine  disease.  In  early  childhood,  even  up  to  twelve 
years  of  age,  acquired  deaf-mutism  is  common. 


Epithelium  of    mucou 
membrane  layer 


Epithelium  destroyed 


External  epithe- 
lium of  dermal 
layer 


Enclosed  serum 
and  pus 


i  desquamated  epithelium 

FIG.  183. — SECTION  OF  DRUM  MEMBRANE;  CASE  OF  CHRONIC  OTITIS  MEDIA  SUPPURATIVA. 
(Prepared  by  Dr.  H.  C.  Low.) 

Granulations  are  found  in  the  middle  ear  and  consist  of  newly 
formed  tissue  composed  of  round  cells  richly  supplied  with  blood-vessels. 
These  new  growths  develop  under  the  influence  of  long-continued 
inflammatory  irritation.  The  superficial  layers  of  the  mucous  mem- 
brane are  destroyed  and  granulomata  spring  up,  at  first  little  papules 
with  raspberry-like  appearance.  These  granulomata  bleed  easily  when 
touched.  They  may  be  covered  with  squamous,  ciliated,  or  columnar 
epithelium,  according  to  where  the  granulomata  are  located,  and  their 
internal  structure  may  become  differentiated.  They  are  called  polypi. 
The  term  polyp  indicates  the  shape  of  the  new  growth  and  does  not 
indicate  the  character  of  its  tissue.  Sometimes  the  polyp  is  covered 


CHRONIC    PURULENT    OTITIS   MEDIA 


323 


with  flat  epithelium  in  one  part  and  with  glandular-like  epithelium  in 
another  part l  (see  Figs.  184  and  185). 


Epidermis  nature  of 
lining  of  canal 


Papilla'   of   nature         Xft 
of  lining  of  tym- ' 
panic  cavity  *87 


Area  of  necrosis 


FIG.  184. — TRANSVERSE  SECTION  OF  AURAL  POLYP. 
(Prepared  by  Dr.  Wales.) 


Papilla 


Gland 


FIG.  185— TRANSVERSE  SECTION  OF  ACRAL  POLYP  SHOWING  CHARACTER  OF  COVERING  EPITHELIUM. 
(From  a  preparation  by  Dr.  Wales.) 

Causation.— Chronic  aural  discharges,  with  the  exception  of  the 
comparatively  few  cases  that  complicate  tuberculosis  or  syphilis,  are 

1  Goerke,  Archiv.  /.  Ohrenheilkunde,  Bd  lii.,  Heft,  i  and  2,  p.  63,  1901. 


324  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

the  sequelae  of  a  preceding  acute  tympanic  inflammation.  The  violence 
of  the  acute  affection  has  usually  been  so  great  that  necrosis  of  the 
mucous  membrane  or  osseous  structures  has  taken  place  to  such  an 
extent  that  nature,  even  when  assisted  by  rational  treatment,  is  unable 
to  repair  the  damage  and  consequently  the  disease  has  become  chronic. 
Chronicity  of  the  discharge  will  probably  result  if,  during  the  acute 
stage,  the  perforation  in  the  drum  membrane  is 
too  small  to  permit  free  drainage.  Failure  on  the 
part  of  the  physician  to  apply,  during  the  acute 
stage  and  at  the  earliest  possible  moment,  the 
well-established  principles  of  treatment  is  also 
responsible  for  many  chronic  cases. 

The  presence  of  adenoids,  nasal  inflammation, 
FIG.  185  a.— AURAL  POLY-     and    new   growths    in    either  the  nose  or  naso- 

PUS  SPRINGING  FROM  ATTIC          .  .  .  . 

AND  PARTIALLY  FILLING  EX-  pharynx  have  the  unquestioned  tendency  to  pro- 
TERNAL  MEATUS.  jong  an  acu^e  purulent  otitis  into  the  chronic 

form.  Whatever  may  have  been  the  cause  of  failure  to  arrest  the 
suppurative  disease  in  its  incipiency,  if  it  continues  beyond  a  period 
of  six  to  eight  weeks  it  is,  by  common  consent,  said  to  be  chronic. 

Prognosis. — The  points  of  most  concern  as  to  prognosis  relate  to 
the  cessation  of  the  discharge,  the  restoration  of  the  impaired  hearing, 
and  the  danger  to  the  life  of  the  individual.  A  trustworthy  prognosis 
is  impossible  unless  an  examination  has  been  made  with  sufficient 
accuracy  to  determine  the  location  and  extent  of  the  middle-ear  disease 
as  well  as  the  complications  which  may  be  present  in  a  given  case. 

Long  process  of  incus 
Crura  of  stapes  -  ^^^^^^^  } 

^^"          Course  of  chorda  tympani  nerve 


FIG.  186. — RIGHT  DRUM  MEMBRANE  WITH  TRANSPARENCY  EXAGGERATED,  SHOWING  COURSE  OF  CHORDA 
TYMPANI  NERVE  AND  THE  RELATION  or  THE  OSSICLES  AS  SEEN  THROUGH  A  SPECULUM. 

In  the  milder  forms,  where  the  disease  has  become  chronic  from  the 
neglect  of  aural  cleanliness  or  from  the  presence  of  adenoids  or  nasal 
growths,  and  when  there  is  no  bone  involvement,  the  discharge  may  be 
said  to  be  always  curable.  Even  where  granulations  or  polypi  are 
present  or  when  one  or  more  ossicles  are  necrosed,  the  discharge  will 
cease  after  the  complete  removal  of  the  offending  parts.  When  the 


CHRONIC    PURULENT   OTITIS    MEDIA  325 

osseous  tympanic  walls  are  denuded  of  their  covering  membrane  to  any 
considerable  extent,  and  particularly  if  the  tegmen  antri,  tegmen  tym- 
pani,  or  other  distant  and  more  inaccessible  parts  are  affected,  the  prog- 
nosis as  to  cure  of  the  discharge  is  bad,  except  as  a  result  of  the  most 
skilful  and  well-directed  mastoid  surgery. 

The  fact  is  now  generally  recognized  that  grave  danger  to  life  attends 
the  majority  of  all  chronic  suppurative  ear  diseases.  It  is  becoming 
apparent  that,  excepting  traumatic  and  systemic  causes,  nearly  if  not 
all  suppurative  and  inflammatory  affections  within  the  cranial  cavity 
have  their  origin  in  an  infected  condition  of  one  or  more  of  the  air  spaces 
which  lie  in  close  proximity  to  the  base  of  the  brain.  Two  of  these 
spaces,  the  middle  ear  and  mastoid  antrum,  lie  in  such  intimate  relation 
to  the  dura  mater  of  the  cerebrum  and  cerebellum  that  infection  of 
these  latter  structures  would  seem  an  almost  inevitable  consequence 
of  a  prolonged  suppuration  within  the  former. 

When  the  attic  of  the  ear  and  the  adjoining  mastoid  antrum  are 
involved,  and  the  osseous  walls  of  these  cavities  are  invaded  by  the 
destructive  process,  the  dangers  of  intracranial  extension  are  always 
grave.  If  cholesteatoma  is  present  softening  of  the  surrounding  bone 
takes  place  from  the  pressure  of  the  mass,  thus  exposing  the  brain  and 
sigmoid  sinus  to  almost  certain  infection  unless  the  progress  of  the 
disease  is  promptly  arrested  by  surgical  interference. 

The  results  of  treatment  for  the  restoration  of  the  impaired  hearing 
are  usually  unsatisfactory.  The  original  disease  has  in  most  cases 
wrought  irreparable  damage.  A  drum  membrane  or  ossicle  that  is 
once  destroyed  by  the  chronic  suppurative  process  can  never  be  restored 
to  usefulness.  Where  the  impairment  of  hearing  is  largely  due  to  a 
thickened  mucosa,  to  an  imprisoned  stapes,  or  to  adhesions  of  some 
part  of  the  drum  membrane  or  long  process  of  the  malleus,  appropriate 
treatment  will  often  yield  good  results.  When  the  tympanic  membrane 
and  ossicles  have  been  swept  away  and  the  mucous  membrane  of  the 
middle  ear  becomes  ultimately  "dermoid"  and  dry,  the  hearing  power 
is  often  less  acute  than  during  the  continuance  of  the  discharge. 

Symptoms. — A  large  percentage  of  cases  of  chronic  aural  discharge 
complains  of  nothing  except  the  discharge  itself,  and  this  is  quite  often 
looked  upon  by  the  patient  and  his  friends  as  a  trivial  annoyance  which 
is  scarcely  worth  the  trouble  required  for  treatment.  Among  the  more 
careless  or  ignorant  it  is  not  unusual  to  find  those  who  have  had  running 
ears  for  long  periods,  and  yet  have  never  thought  it  necessary  to  do 
more  than  to  wipe  away  the  pus  when  it  appeared  externally  in  the  audi- 
tory meatus. 


326  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

The  amount  of  discharge  varies  in  different  cases  from  that  so 
profuse  as  to  fill  the  auditory  meatus  several  times  a  day  to  a  quantity 
so  small  that  it  seldom  or  never  wets  the  whole  auditory  canal.  When 
produced  in  such  minute  quantity  the  pus  dries  about  the  edges  of  the 
membranous  perforation  or  upon  the  adjacent  meatal  walls  into  hard 
masses,  in  which  condition  it  is  easily  mistaken  for  inspissated  ear  wax. 
This  class  of  patient  will  state  that  formerly  his  ear  discharged,  but  he 
is  apt  to  believe  that  for  a  long  time  it  has  been  absolutely  free  from 
any  suppuration. 

The  pus  may  be  mucopurulent  and  stringy,  thin  and  sanious,  or 
creamy  and  yellow,  depending  much  upon  the  particular  part  of  the 
middle  ear  most  affected  and  upon  the  kind  of  tissue  involved.  Mucoid 
discharges  are  found  in  cases  in  which  the  lower  portion  of  the  drum 
cavity  and  Eustachian  tube  are  the  chief  seats  of  the  disease,  while 
creamy  pus  usually  originates  in  a  diseased  attic  or  mastoid  antrum. 
A  bloody  discharge  occasionally  occurs  in  cases  where  granulations  or 
polypi  are  present,  since  these  growths  are  highly  vascular  and  the 
vessels  so  thin  walled  that  the  bleeding  may  take  place  spontaneously. 
The  occurrence  of  such  a  hemorrhage  is  indicative  of  no  additional 
gravity,  but  becomes  important  from  the  fact  that  the  patient  is  suffi- 
ciently alarmed  by  it  to  seek  curative  measures  at  once,  whereas  pre- 
viously he  had  been  entirely  satisfied  with  nature's  indefinite,  un- 
certain, and,  perhaps,  dangerous  course. 

In  the  mildest  cases  and  those  that  have  received  proper  care  in  the 
way  of  cleansing,  the  pus  may  have  little  or  no  odor.  In  many  cases, 
however,  even  after  the  most  thorough  cleansing  possible,  the  penetrating 
odor  of  the  purulent  discharge  persists  and  is  often  characteristic  of 
chronic  aural  suppuration.  Fetid  odor  is  present  in  attic  necrosis  in 
connection  with  involvement  of  the  ossicular  chain,  and  especially  in 
cases  where  cholesteatomatous  masses  are  present  in  the  tympanic 
cavity.  Such  odors,  here  as  elsewhere,  are  due  to  retention  and  decom- 
position of  the  secretions  or  to  decay  of  the  soft  or  bony  structures,  and 
can,  in  most  cases,  be  permanently  arrested  only  by  providing  perfect 
drainage  and  after  complete  obliteration  and  removal  of  the  diseased 
tissues.  Chronic  suppurative  otitis  media  sometimes  results  in  the 
destruction  of  the  chorda  tympani  nerve,  which  traverses  the  upper 
anterior  portion  of  the  cavity  of  the  middle  ear  (see  Fig.  186;  also  Fig. 
24).  When  this  takes  place  the  patient  complains  of  a  disturbance 
of  taste  on  the  lateral  half  of  the  tongue  corresponding  to  the  affected 
ear.  Complaint  is  also  occasionally  made  that  there  is  present  in  the 
mouth  a  continual  bad  taste.  This  latter  is  due  to  the  fact  that  some 


CHRONIC    PURULENT   OTITIS    MEDIA  327 

of  the  aural  discharge  finds  its  way  into  the  nasopharynx  and  mouth 
through  the  patulous  Eustachian  tube.  Severe  stomach  and  intestinal 
disturbances  have  been  known  to  follow  when  the  patient  swallows  the 
pus,  which  thus  finds  its  way  into  the  pharynx  through  the  Eustachian 
tube. 

Facial  paralysis  is  also  an  occasional  symptom,  particularly  when 
the  aural  suppuration  is  complicated  by  cholesteatoma,  mastoiditis,  or 
labyrinth  necrosis.  The  facial  palsy  occurring  in  this  connection  may 
be  the  result  of  an  extension  of  the  inflammation  and  infection  into  the 
Fallopian  canal,  in  which  instance  an  inflammatory  exudate  takes  place 
about  the  nerve  sheath,  and  the  pressure  consequent  upon  the  increased 
amount  of  fluid  is  sufficient  to  inhibit  the  function  of  the  nerve.  The 
facial  nerve  may  be  invaded  by  necrosis  of  the  bone  comprising  the 
canal,  a  sequestrum  may  form,  and  the  nerve  trunk  may,  as  a  result, 
be  exposed  to  direct  infection  from  the  middle  ear.  In  such  case  the 
exposed  portion  of  the  nerve  trunk  may  be  completely  destroyed;  or, 
as  a  result  of  the  exposure  of  the  nerve  from  necrosis,  granulations  or 
polypi  may  spring  up  over  the  site  of  the  diseased  bone,  the  pressure 
from  which  may  be  great  enough  to  impair  the  nerve  or  even  to  com- 
pletely destroy  it  for  a  considerable  distance. 

The  hearing  power,  even  when  there  has  been  considerable  destruc- 
tion of  the  drum  membrane,  ossicles,  and  other  tissues  of  the  middle  ear, 
often  remains  so  good  that  the  patient  makes  little  or  no  complaint 
concerning  it.  Even  when  the  tympanic  membrane,  hammer,  and 
incus  have  been  entirely  swept  away  by  the  violence  of  the  original 
disease,  the  patient  may  yet  be  able  to  hear  the  conversational  voice 
quite  well.  Children  who  have  suffered  such  destruction  of  the  middle- 
ear  structures  as  a  result  of  measles,  scarlet  fever,  or  other  violent  diseases, 
are  subsequently  often  able  to  attend  school  with  remarkably  slight 
inconvenience  from  the  resulting  deafness. 

All  chronic  suppurative  middle-ear  cases,  however,  are  not  so  for- 
tunate in  this  respect,  for  in  some,  labyrinthine  inflammation  or  even 
suppuration  may  be  a  complication  from  the  first,  in  which  instance  the 
loss  of  hearing  is  always  much  greater  and  is  sometimes  complete. 
When  very  considerable  impairment  occurs  in  the  very  young,  deaf- 
mutism  is  an  inevitable  consequence  (see  Chapter  XL VIII.).  Deafness 
is  also  more  pronounced  when  in  the  course  of  the  long-continued  dis- 
charge the  foot-plate  of  the  stapes  becomes  imbedded  and  immovably 
fixed  in  the  oval  window  by  the  formation  of  connective  tissue  over 
and  about  it.  Connective-tissue  deposits  in  the  round  window,  ad- 
hesions of  the  handle  of  the  malleus  to  the  promontory,  and  ankylosis 


328  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

of  the  ossicular  chain  may  occur  singly  or  together  during  the  progress 
of  any  case,  and  when  present  will  greatly  impair  the  hearing  power 
of  the  individual. 

Pain  is  not  a  prominent  symptom  of  this  disease.  Patients  are 
not  uncommon  who  have  had  running  ears  for  many  years  with  absolutely 
no  suffering  since  the  onset  of  the  ailment.  When  present  in  any  case 
pain  is  indicative  of  imperfect  drainage.  Either  the  perforation  that 
was  formerly  ample  for  the  purpose  has  become  too  small  from  gradual 
closure,  or  else  a  granulation,  polypus,  or  crust  of  dried  secretion  is 
blocking  the  opening  and  retaining  the  pus  under  pressure..  When  the 
suppurative  process  has  extended  to  the  mastoid  antrum  and  cells  a 
free  outlet  for  the  pus  through  the  middle  ear  is  frequently  no  longer 
possible,  and  this  is  often  a  cause  of  suffering,  either  as  a  result  of  the 
pent-up  pus  or  of  the  periosteal  inflammation  and  external  swelling 
which  is  produced  by  the  fluid  in  its  effort  to  liberate  itself  through 
some  part  of  the  temporal  bone. 

Tinnitus  aurium  is  present  in  many  cases,  but  seldom  with  such 
intensity  as  that  which  accompanies  chronic  non-suppurative  aural 
inflammation.  The  head  noises  are  oftenest  found,  when  coexistent 
with  chronic  suppuration,  in  those  cases  where  physical  examination 
reveals  the  presence  of  adhesions  of  the  remnant  of  the  drum  membrane 
to  the  inner  tympanic  wall  or  of  the  long  process  of  the  malleus  to  the 
promontory.  Tinnitus  is  also  very  apt  to  result  from  the  imprisonment 
of  the  foot-plate  of  the  stapes  in  the  oval  window,  which  occurs  as  a 
consequence  of  the  connective  tissue  that  is  deposited  about  it  during 
the  long  course  of  the  disease.  This  symptom  is  also  present  in  an 
exaggerated  form  in  many  patients  in  whom  the  aural  discharge  has 
ceased  for  weeks  or  months,  but  with  resultant  cicatrization  and  con- 
traction of  all  the  middle-ear  tissues  which  were  formerly  inflamed  and 
suppurating. 

Dizziness  becomes  an  annoying  symptom  in  some  cases.  It  may 
occur  only  at  the  time  the  ear  is  syringed  or  otherwise  treated  or  it 
may  be  constantly  present  and  so  severe  that  the  patient  is  unsafe  when 
walking  abroad  alone.  Where  faintness  occurs  when  the  ear  is  irrigated, 
it  is  usually  due  to  the  presence  of  a  large  opening  through  the  drum 
membrane  which  permits  the  fluid  entering  the  ear  to  strike  the  oval 
window  with  considerable  force.  If  the  dizziness  is  constant  and 
severe,  labyrinthine  involvement  should  be  suspected. 

The  symptoms  of  the  complicating  ailments  which  may  arise  in  the 
course  of  the  disease,  for  example,  mastoiditis  and  the  various  intra- 


CHRONIC    PURULENT   OTITIS    MEDIA 


329 


cranial  affections,  are  more  properly  discussed  in  chapters  devoted  to 
this  subject  (see  p.  353,  Chapter  XXVIII.). 

Diagnosis. — i.  Physical  Examination. — Preceding  any  examination 
of  the  drum-head  in  which  there  are  suspected  changes  in  its  position, 
thickness,  color,  or,  more  particularly,  if  there  is 
a  probable  loss  of  a  large  portion  of  the  mem- 
brana  (Fig.  191),  the  examiner  will  do  well  to 
recall  the  landmarks  of  the  normal  structure.  For 
purposes  of  rendering  intelligible  the  description 
of  the  pathologic  condition  that  may  be  found, 
and  in  order  that  the  results  of  the  inspection 
may  be  properly  recorded,  the  quadrants,  their  FIG.  187.— THE 

1,.  J       1  1-  11111  i  RANTS    OF    THE    DRUM-HEAD 

location  and  boundaries,   should  also   be    noted     VIEWED  THROUGH  A  SPECU- 
(Fig.  187).  LUM- 

In  no  branch  of  medicine  or  surgery  is  a  painstaking  and  thorough 
examination  into  the  exact  state  of  the  diseased  parts  more  necessary 
to  successful  treatment  than  in  chronic  otitis  media  purulenta.  Neither 
empiricism  nor  inference  has  a  place  among  modern  methods,  as  they 
pertain  to  the  diagnosis  of  chronic  discharging  ears.  Every  feature 
of  the  disease  as  presented  by  each  individual  patient  must  be  noted 
and  given  proper  significance.  In  any  case  of  chronic  otorrhea  the 
disease  may  have  extended  to  the  mastoid  region.  Indeed,  such  com- 
plication may  have  constituted  the  patient's  sole  reason  for  consulting 
the  physician.  However  this  may  be,  as  a  first  step  of  the  examination 
the  region  of  the  mastoid  process  should  be  inspected,  and  comparison 
made  with  the  corresponding  portions  of  the  opposite  side,  in  order  to 
determine  if  there  be  present  any  tenderness,  redness,  swelling,  or  fistula 
leading  into  the  mastoid  antrum  or  cells.  During  this  part  of  the 
examination  the  patient  is  placed  with  his  back  toward  a  good  light 
from  a  window,  in  which  position  any  malposition  or  tumefaction  about 
the  auricle  will  be  readily  noted.  If  there  is  much  swelling  behind  the 
ear  and  over  the  mastoid  or  in  the  posterior  wall  of  the  external  audi- 
tory meatus,  the  pinna  will  be  pushed  forward  so  as  to  stand  most 
noticeably  away  from  the  head  and  will  cause  the  latter  to  appear  de- 
cidedly unbalanced  (see  Fig.  181).  Pressure  over  the  tip  of  the  mastoid 
process  at  the  point  of  exit  of  the  mastoid  vein  and  over  the  site  of  the 
mastoid  antrum  should  not  be  neglected,  because  in  disease  of  the 
underlying  cavities  these  situations  are  most  constantly  sensitive  to  deep 
pressure  (see  Fig.  151).  Should  a  mastoiditis  have  existed  for  a  long  time 
as  a  complication  of  the  chronic  discharge  in  the  tympanic  cavity,  there 
is  a  possibility  that  the  bony  cortex  and  soft  tissues  covering  the  mastoid 


330  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

process  may  have  ruptured,  leaving  a  discharging  fistula  in  the  post- 
auricular  area  (Fig.  188).  Such  an  occurrence  may  be  best  observed 
with  the  patient  in  the  above  position,  which  is  also  a  favorable  one 
for  gently  probing  any  such  sinus  in  order  to  ascertain  the  depth  and 
direction  of  the  channel,  and  also  to  learn  whether  or  not  bony  sequestra 
or  necrotic  areas  lie  in  its  tract.  The  condition  of  postaural  fistula 
leading  to  deep  foci  of  disease  is  one  calling  urgently  for  operative 
measures,  and  although  the  patient  may  make  little  or  no  complaint 
concerning  it,  experience  has  shown  that  there  is  the  gravest  danger 
of  extension  of  the  disease  to  the  sigmoid  sinus,  where  thrombosis  may 


FIG.  188. — POSTAURAL  FISTULA  OF  LONG  DURATION  RESULTING  FROM  ACUTE  MASTOIDITIS. 
Chronic  tympanic  and  mastoid  suppuration  were  present  at  the  time  the  drawing  was  made.     A  radical   mas- 

toid  operation  was  performed. 

be  produced,  to  the  meninges  causing  meningitis,  or  to  the  cerebral  or 
cerebellar  structures,  where  abscess  may  result. 

The  patient  is  next  placed  in  the  examining  chair  in  proper  position 
to  use  reflected  artificial  light.  The  external  meatus  is  first  inspected 
and  the  lumen  of  its  canal  noted.  In  cases  where  there  has  been  a 
discharge  covering  a  period  of  several  years,  or  perhaps  only  a  few 
months  if  the  discharge  has  been  irritating,  the  skin  lining  the  meatus  at 
times  becomes  greatly  thickened,  fissured,  or  eczematous,  any  one  of 
which  complications  may  have  caused  the  patient  more  annoyance 
or  suffering  than  the  primary  ailment.  Accumulations  of  epithelia  or 
of  inspissated  pus  or  cerumen  are  sometimes  seen  lying  more  deeply 
in  the  canal,  all  of  which  must  be  removed  before  an  examination  of 
the  drum  membrane  or  middle  ear  can  be  satisfactorily  made.  If  a 


CHRONIC    PURULENT   OTITIS   MEDIA 


331 


crust  of  dried  secretion  is  found  covering  Shrapnell's  membrane  and 
the  adjacent  superoposterior  wall  of  the  external  meatus  (Fig.  189), 
the  same  possibly  indicates  a  perforation  of  the  membrane  above  the 
short  process  of  the  malleus  (Fig.  199).  Examination  of  the  crust  after 
it  is  removed  will  show  its  composition  to  be  dried  pus.  Accumula- 
tions in  this  region  are  often  pathognomonic  of  attic  disease  and  in  such 
instance  the  surgeon  should  be  cautious  not  to  state  to  the  patient  that 
the  same  is  ear  wax  and  that  the  condition  is,  therefore,  a  trivial  one. 
The  external  meatus,  having  been  cleared  of  all  obstruction  by 
syringing  or  by  the  use  of  appropriate  instruments  used  under  the 
direction  of  the  eye  and  a  good  reflected  light,  the  examination  of  the 
membrana  tympani  and  middle-ear  cavities  is  begun.  A  proper-sized 
speculum  is  inserted  and  the  canal  straightened  by  traction.  It  cannot 


FIG.  189. — CRUST  OF  DRIED  Pus  COVERING 
PERFORATION  IN  SHRAPNELL'S  MEMBRANE  AND 
EXTENDING  OUTWARD  INTO  AUDITORY  CANAL. 

Fig.  199  shows  perforation  in  Shrapnell's  mem- 
brane after  crust  has  been  removed. 


FIG.  190. — CHOWS  THE  RELATIVE  FREQUENCY 
OF  PERFORATION  IN  EACH  QUADRANT  OF  THE 
DRUM-HEAD  IN  1000  CASES,  AS  OBSERVED  BY 
B.  A.  RANDALL. 


be  too  often  repeated  that  the  patient's  auricle  must  be  lifted  strongly 
upward  and  backward  until  the  canal  is  straightened,  for  in  this  position 
only  it  is  possible  for  the  light  to  penetrate  to  the  fundus  in  sufficient 
volume  to  fully  illuminate  the  drum  membrane.  The  observer  will  first 
note  the  presence  or  absence  of  the  landmarks  (see  Fig.  96)  and  normal 
color,  the  disappearance  or  modification  of  which  will  bear  a  close  rela- 
tion to  the  amount  of  disease  or  destruction  of  the  membrane.  The 
membrana  tympani  may  have  become  thickened,  perforated,  or  otherwise 
pathologically  altered  in  any  portion  of  its  structure.  The  whole  mem- 
brane may  have  been  swept  away  by  the  violence  of  the  original  ailment 
or  only  portions  or  all  of  a  given  quadrant  may  be  found  wanting.  While 
any  shape,  size,  or  position  1  of  the  perforation  may  be  present,  certain 
types  are  seen  in  practise,  the  most  common  being  the  following: 

1  B.  A.  Randall,  Trans.  Otol.  Section,  A.  M.  A.,  1898,  gives  the  tabulated  result  of  a 
study  of  the  location  of  1000  consecutive  cases  of  perforation  of  the  drum-head. 
Fig.  190  graphically  represents  the  position  of  the  different  groups  of  perforation  by 
quadrants. 


332 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


(a)  The  short  process  and  all  or  portions  of  the  handle  of  the  malleus 
remain  intact  even  when  large  portions  of  the  surrounding  drum  mem- 
brane have  been  destroyed,  the  projecting  handle  with  its  remnant  of 


FIG.    IQJ. — Loss  or  GREATER   PORTION  OF  THE 

MEMBRANA  TENSA. 
The  long  process  of  the  malleus  remains  intact. 


FIG.  192.— PERFORATION  IN  ANTKRO-INFERIOR 
QUADRANT,  NEAR  THE  TYMPANIC  ORIFICE  OF  THE 
EUSTACHIAN  TUBE. 


membrane  attached,  forming  a  kind  of  peninsula,  which  will  be  seen 
extending  from  above  downward  and  backward  in  normal  position  (Fig. 

191).  Sometimes  in  such  in- 
stances the  umbo  is  adherent 
to  the  promontory,  in  which 
case  the  condition  is  not  so 
clearly  made  out  by  vision 
alone,  and  when  such  is  the 
case  the  probe  can  be  effici- 
ently employed  to  determine 
this  point. 


FIG.  193. — POSITION  OF  PATIENT'S  HEAD  WHILE  INSPECTING  THE 

ANTERIOR  PORTION  OF  THE  DRUM  MEMBRANE. 
The  face  is  turned  somewhat  away  from  the  examiner. 


FIG.  194. — PERFORATION  POSTERIOR 
TO  THE  UMBO. 


(&)  Perforation  in  the  antero-inferior  quadrant,  near  the  site  of 
entrance  of  the  Eustachian  tube,  the  shadow  of  the  mouth  of  which  is 
often  visible  if  the  opening  into  the  drum  cavity  is  sufficiently  large 
(Fig.  192).  A  perforation  of  the  membrane  in  this  locality  is  best  seen 
when  the  patient's  face  is  turned  slightly  away  from  the  examiner,  who 
looks  along  the  rays  of  light,  which  should  penetrate  the  depths  of  the 
ear  somewhat  in  the  direction  of  the  tip  of  the  patient's  nose  (Fig.  193). 


CHRONIC   PURULENT   OTITIS   MEDIA  333 

Perforations  in  this  location  have  usually  originated  from  some  mild 
infective  process  which  became  chronic  either  because  of  inefficient  treat- 
ment or  from  the  existence  of  a  catarrhal  affection  in  the  nose  or  naso- 
pharynx. The  presence  of  an  adenoid  is  a  great  hindrance  to  the  cure 
of  any  aural  discharge,  but  is  particularly  influential  in  keeping  alive 
the  tubal  and  middle-ear  inflammation  with  its  mucopurulent  secretion 
in  cases  of  perforation  in  this  quadrant.  Very  rarely  are  the  osseous 
tissues  carious  or  necrotic  in  this  class  of  perforation. 

(c)  Perforation  behind  the  handle  of  the  malleus  near  its  tip  (Fig. 
194).  This  class  usually  occurs  in  childhood  and,  like  the  preceding,  is 
most  likely  the  result  of  neglect,  of  the  presence  of  nasopharyngeal 
inflammation,  or  of  adenoids.  It  represents  the  least  difficult  class  to 


FIG.  195. — POSITION  OF  PATIENT'S  HEAD  DURING  THE  EXAMINATION  OF  THE  CENTRAL  PORTIONS  OF  THE 

DRUM-HEAD,  INCLUDING  THE  HANDLE  OF  THE  MALLEUS  AND  UMBO. 

Head  erect  and  face  forward. 

cure,  since  there  are  commonly  few  important  changes  in  the  middle  ear 
itself  and  polypi  seldom  spring  from  the  edges  of  the  opening.  The 
proper  position  of  the  patient's  head  for  examining  this  portion  of  the 
drum  membrane  is  shown  in  Fig.  195. 

(d)  A  class  in  which  the  membranous  rupture  lies  below  the  posterior 
fold  and  covers  the  site  of  the  incudostapedial  articulation  (Fig.  196). 
Unlike  the  two  preceding  varieties,  this  one  represents  more  deep-seated 
and  violently  destructive  pathologic  conditions  within  the  drum  cavity. 
Polypi  frequently  arise  from  within,  grow  through  the  perforation,  and 
wholly  or  partially  fill  the  auditory  canal.  Adhesions  of  the  margins 
of  the  perforated  membrane  below  and  on  each  side  to  the  adjacent 
mucous  lining  of  the  middle  ear  often  occur,  but  the  upper  margins 


334  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

remain  free,  forming  the  mouth  of  a  channel,  the  other  extremity  of 
which  is  usually  high  in  the  attic.  Necrosis  of  one  or  more  ossicles  or 
of  some  portion  of  the  adjacent  bony  walls  is  common,  and  mastoid 
involvement  is  not  an  infrequent  complication. 

(e)  Destruction  of  practically  the  whole  membrana  tensa.  In 
such  cases  there  is  apt  to  remain  a  rim  of  thickened  membrane  along 
the  whole  line  of  attachment  of  the  drum-head  to  the  annulus  tympan- 
icus  (Fig.  197).  The  membrana  flaccida — ShrapnelPs  membrane — is 
usually  present,  but  has  become  in  most  instances  so  much  thickened, 
granular,  or  polypoid  as  to  be  wholly  changed  from  the  normal.  Some- 
times the  short  process  and  neck  of  the  malleus,  together  with  the  stump 
of  its  handle,  may  be  seen  or  felt  with  the  probe  imprisoned  in  the 
diseased  tissues.  The  incus  has  usually  suffered  death,  has  already 
been  discharged  with  the  pus,  or  a  remnant  of  the  ossicle  may  be  found 
lying  dislocated  and  useless  in  some  portion  of  the  middle  ear.  If  the 


FIG.  196. — RUPTURE  BELOW  THE  POSTERIOR  FIG.  197. — Loss  OF  GREATER   PORTION  OF  MIM- 

FOLD  OVER  SITE    OF   INCUDOSTAPEDIAL  ARTICU-  BRANA  TENSA. 

LATION.  Stump  of  malleus  handle  remains,  membrana 

flaccida  thickened.     Tympanic  mucous  membrane 
granular. 

head  of  the  patient  be  tilted  far  to  one  side  and  away  from  the  examiner 
(Fig.  198),  the  head  and  portions  of  the  crura  of  the  stapes  may  possibly 
be  visible  if  not  located  too  high,  and  are  not  imbedded  in  granulations 
or  connective  tissue.  In  cases  of  comparatively  short  duration  the 
mucous  lining  of  the  tympanic  cavity  presents  an  inflamed,  thickened, 
and  granular  appearance.  In  this  condition  it  is  not  always  easy  to 
determine  whether  the  drum  membrane  is  present  or  totally  wanting, 
since  the  entire  appearance  may  very  closely  simulate  that  in  which  the 
intact  drum  membrane  is  so  much  thickened  and  inflamed  that  its 
landmarks  are  entirely  obliterated.  Where  the  disease  has  been  of 
long  standing  and  the  suppuration  is  very  scant,  the  tympanic  cavity 
is  sometimes  covered  with  a  dermoid  epithelium  which  has  grown 
inward  from  the  external  meatus,  a  "dermatized"  mucous  membrane, 
that  is  far  less  sensitive  to  the  touch  and  which  serves  none  of  the 


CHRONIC   PURULENT    OTITIS    MEDIA 


335 


secretory  functions  of  the  normal  lining;  but  for  purposes  of  protection 
to  the  widely  exposed  cavity  the  new  covering  is  vastly  superior  to  a 
mucous  membrane. 

(/)  From  the  standpoints  of  pathology,  prognosis,  and  treatment, 
perforations  through  ShrapnelPs  membrane  are  the  most  important. 
These  ruptures  are  of  necessity  small  and  are  most  often  located  imme- 
diately external  to  or  just  above  the  short  process  of  the  malleus  (Fig. 
199).  Their  external  appearance  usually  gives  no  indication  of  the 
serious  nature  of  the  underlying  disease,  and  they  are  entirely  overlooked 
unless  the  examiner  is  both  skilful  and  thorough.  The  small  amount 
of  pus  discharged  through  this  variety  of  perforation  often  dries  as  fast 
as  it  appears  in  the  opening,  and  a  crust  thus  forms  about  the  edges  of 
the  perforation  and  its  adjacent  parts;  this  finally  covers  not  only  the 


FIG.  198.— POSITION  OF  THE  PATIENT'S  HEAD  ros  EXAMINING  FIG.  199. — PERFORATION  IN  SHRAP- 

SHRAPNELL'S  MEMBRANE.  NELL'S  MEMBRANE,  SHOWING  DROP  OF 

The  head  is  inclined  away  from  the  examiner,  the  face  of  the  Pus  IN  OPENING. 

patient  approaching  somewhat  the  horizontal.  Same  case  as  that  shown  in  Fig.  189. 

perforation  but  also  the  whole  of  Shrapnell's  membrane,  and  may  then 
extend  outwardly  along  the  superoposterior  wall  of  the  external  meatus 
(see  Fig.  189).  It  is  such  a  crust  that  is  often  mistaken  for  hardened 
ear  wax  and,  as  previously  stated,  the  surgeon  should  be  warned  against 
the  mistake  of  telling  his  patient  that  the  condition  is  trivial.  Upon 
the  removal  of  this  inspissated  pus,  and  when  the  patient's  head  has 
been  placed  in  a  position  away  from  the  examiner  and  horizontally  to 
one  side,  the  perforation  will  be  seen  filled  with  purulent  secretion 
(Fig.  199).  Examination  of  the  crust  after  its  removal  will  also  show 
its  true  composition.  The  condition  is  one  distinctly  indicative  of 
attic  and  mastoid  involvement.  Necrosis  of  the  head,  neck,  and,  often, 
the  short  process  of  the  malleus  have  usually  taken  place,  and  the 


336 


THE   PRINCIPLES   AND   PRACTICE    OF   OTOLOGY 


osseous  attic  walls  and  mastoid  antrum  are  frequently  involved.  The 
entire  pathology  is  one  to  be  dealt  with  surgically,  since  local  applications 
and  general  medication  have  only  a  subsidiary  place  in  the  treatment. 

Visual  impressions  are  not  always  entirely  reliable  in  aural  diagnosis. 
Conditions  are  often  present  that  would  lead  to  error  if  sight  alone  were 
depended  on.  A  delicate  silver  probe  that  may  be  bent  to  any  suitable 
angle  is  a  most  valuable  aid  in  diagnosis  (Fig. 
200).  A  polypus  projecting  through  the  mem- 
brane, and  partially  or  wholly  filling  the  canal 
(Fig.  201),  can  be  moved  about  by  the  gentle  use 
of  such  an  instrument ;  the  consistency  of  such  a 
growth  and  the  point  of  its  attachment  can  be 
determined,  and  thus  a  positive  diagnosis  of  the 
nature  of  the  tumor  can  be  made.  Foreign 
bodies  at  the  fundus  of  the  meatus  are  apt  to 
be  mistaken  for  new  growths  unless  the  probe 
be  delicately  and  intelligently  used  to  aid  the 


FIG.  200. — DELICATE  SILVER 
AURAL  PROBE. 


FIG.  201. — AURAL  POLYPUS  PROJECTING  INTO  THE  CONCHA. 

See  microphotographs  (Figs.  185  and   186)  prepared  from  growth  here 

shown. 


examination.  Necrosis  of  an  ossicle  or  of  any  part  of  the  bony 
walls  of  the  drum  cavity  can  be  detected  with  certainty  only  by 
the  dextrous  use  of  this  little  instrument.  During  the  examination 
it  is  often  necessary  to  bend  and  rebend  the  probe  until  that  par- 
ticular angle  is  found  that  will  enable  the  instrument  to  follow  the 
diseased  parts  into  the  depths  to  which  the  latter  have  extended.  Should 
the  tip  of  the  probe  touch  uncovered  bone,  the  grating  sensation  im- 


CHRONIC    PURULENT   OTITIS   MEDIA 


337 


parted  to  the  hand  of  the  examiner  is  unmistakable.  The  situation  of 
any  carious  region  should  be  noted  and  the  probable  tissue  involved 
should  be  determined,  in  order  that  proper  measures  may  be  more  ration- 
ally applied  in  the  subsequent  treatment.  The  region  behind  and 
above  the  short  process  of  the  malleus  should 
always  be  most  thoroughly  inspected  with  the 
probe  in  any  case  in  which  the  drum  mem- 
brane is  seen  to  be  perforated  near  this  land- 
mark. It  is  a  well-known  pathologic  fact  that 
the  largest  number  of  chronic  discharging  ears 
follows  acute  suppuration  in  the  attic,  and  • 
when  such  discharges  result  from  the  violent 

FIG.  202. — Loss  OF  GREATER 

infectious     diseases      Of      childhood,    necrosis    in       PORTION  OF  DRUM-HEAD  INCLUD- 
.,   .       ,          ,..  MI        i  ,     •    i       i         r  i    -I-       ING  HEAD  AND   MOST  OF  MAL- 

this  locality  will   almost  certainly  be  found  if     LEUS  HANDLE. 

sought  for  with  sufficient  persistence  and  skill.     Aural  P°lypi  Fresent-   Ossiculec- 

...  .  ,  tomy ;  curettage ;  recovery. 

Ine  head  ot  the  malleus  is  sometimes  largely 

or  wholly  destroyed,  the  perforated  drum  membrane  being  covered  by 

one  or  more  polypi  that  spring  from  the  necrotic  tissues  (Fig.  202). 

The  posterosuperior  wall  of  the  external  meatus  should  also  receive 
careful  consideration  in  this  examination,  because  if  the  suppuration 
in  the  middle  ear  is  of  long  standing,  and  especially  if  the  mastoid  has 
been  involved,  there  sometimes  exists  a  perforation  in  this  location 
which  leads  not  only  through  the  soft  tissues  of  the  external  auditory 
canal  but  also  penetrates  deeply  into  the  underlying  osseous  structures. 
The  probe  should  be  entered  into  the  mouth  of  any  such  fistula  and  the 
direction  and  extent  of  the  channel  thus  be  ascertained.  Sequestra  or 
carious  bone  can  in  this  way,  even  though  they  lie  deeply  in  the  mastoid 
process,  usually  be  detected.  Polypi  or  granulations  sometimes  spring 
from  the  external  orifice  of  these  fistulae,  and  may  require  removal 
before  the  aperture  of  the  same  can  be  seen.  The  presence  of  a  fistula 
in  this  location  is  pathognomonic  of  chronic  mastoiditis. 

(2)  Functional  Examination  oj  the  Ear. — The  voice,  whisper,  and 
watch  tests  indicate  a  loss  of  the  hearing  power  which  varies  greatly 
in  different  individuals.  Even  when  much  destruction  of  the  drum 
membrane  and  tissues  of  the  middle  ear  have  taken  place,  the  hearing 
may  be  found  to  be  but  moderately  impaired.  When  the  suppuration 
is  complicated  by  a  labyrinthine  involvement  the  greatest  degree  of 
deafness  is  usually  found.  Tuning-fork  tests  will  show  that  the  lowest 
notes  are  heard  but  poorly  if  at  all,  whereas,  unless  there  is  a  labyrinthine 
complication,  the  higher  tones  will  be  heard  quite  well.  Bone  conduc- 
tion is  better  than  air  conduction  (be  >  ac)  in  uncomplicated  cases,  and 
22 


338  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

if  only  one  ear  is  involved  in  the  chronic  suppurative  process,  the  tuning- 
fork  will  be  heard  better  on  the  diseased  side  when  placed  while  vibrating 
upon  the  median  line  of  the  skull  or  against  the  upper  central  incisor 
teeth  (Weber's  test). 

In  case  the  labyrinth  has  become  involved,  and  a  mixed  deafness 
is  present,  both  the  high  and  low  notes  of  the  tuning-fork  will  be  heard 
poorly  or  not  at  all.  If  the  labyrinthine  deafness  predominates  over 
that  caused  by  the  damage  to  the  middle  ear,  the  vibrating  C2  fork, 
when  placed  upon  the  center  line  of  the  head,  will  probably  be  heard 
better  in  the  better  ear,  and  air  conduction  will  be  better  than  bone 
conduction — ac  >  be,  or  Rhine,  is  said  to  be  positive — Rinne  + . 

The  treatment  of  chronic  purulent  otitis  is  both  medicinal  and 
surgical,  and  will  be  considered  in  the  two  succeeding  chapters. 


CHAPTER  XXVII 
CHRONIC  PURULENT  OTITIS  MEDIA  (Continued) 

THE  MEDICINAL  TREATMENT 

IN  chronic  purulent  otitis  media,  as  in  ailments  in  other  parts  of  the 
body,  successful  treatment  must  be  based  upon  accurate  diagnosis. 
Hence,  before  curative  measures  are  attempted  a  definite  conclusion 
as  to  the  exact  character  of  the  disease,  its  pathology,  extent,  and  situation 
should  first  have  been  determined.  An  aural  discharge  may  result 
from  an  abscess  or  other  affection  of  the  external  meatus ;  from  necrosis, 
inflammation,  or  new  growths  in  the  middle  ear,  or  the  pus  may  have  its 
origin  in  more  than  one  or  even  the  entire  chain  of  air  spaces  that 
communicate  with  the  drum  cavity — namely,  the  mastoid  antrum  and 
the  mastoid  cells.  Disease  of  the  Eustachian  tube  sometimes  not  only 
perpetuates  a  suppurative  process  within  the  middle  ear,  but  may  itself 
furnish  a  part  of  the  muco-purulent  material  which  constitutes  the 
aural  discharge. 

Considering  the  widely  different  sources  of  the  discharge  and  the 
varying  amount,  character,  and  location  of  the  disease  producing  the 
same,  it  is  evident  that  no  single  plan  of  treatment  will  prove  sufficient 
to  effect  a  cure  in  all.  The  several  steps  of  the  management,  each 
based  upon  the  well-established  principles  of  aural  practise,  and  the 
correct  diagnosis  of  the  individual  case,  are  therefore  given  somewhat 
in  the  order  in  which  they  may  be  most  conveniently  studied. 

(i)  Constitutional  Treatment. — In  a  considerable  number  of 
cases  of  chronic  aural  discharge,  it  will  be  found  that  constitutional 
conditions  exist  which  are  either  entirely  or  partly  responsible  for  the 
continuance  of  the  local  disease.  Chief  among  these  are  tuberculosis, 
scrofula,  syphilis,  and  anemia.  Impaired  nutrition  from  whatever  cause 
will  require  the  most  rational  constitutional  treatment.  If  the  general 
symptoms  and  local  pathology  point  certainly  to  tuberculosis,  all  modern 
knowledge  that  pertains  to  the  treatment  of  this  disease  should,  in 
connection  with  local  medication,  be  rigidly  carried  out.  Open  air, 
sunshine,  suitable  food,  and  exercise  in  proportion  to  the  physical  strength 
of  the  patient  are  essential.  Creosote  or  guaiacol,  if  well  borne  by  the 
stomach,  must  yet  be  regarded  as  possessing  first  medicinal  value. 

339 


340  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

Syphilitic  aural  complications  are  rare  in  chronic  suppurative  otitis 
and  occur  most  frequently  in  the  third  stage  of  the  luetic  disease.  Hence, 
the  iodids  of  potassium  or  sodium  prove  most  serviceable  if  given  in 
increasing  doses  and  until  their  effect  on  the  local  ear  lesion  is  noticeably 
beneficial,  after  which  time  gradual  reduction  of  the  dosage  may  be  made. 
The  author  has  no  faith  in  the  efficacy  of  small  and  infrequent  doses 
of  this  remedy,  but  has  witnessed  satisfactory  results  after  saturation 
of  the  patient  with  the  drug  has  been  accomplished. 

(2)  Nasal    and     Nasopharyngeal     Management. — Many    aural 
patients  are  seldom  free  from  head  colds,  which  materially  increase 
the  aural  suppuration  and  hinder  or  make  useless  the    best-directed 
efforts  of  local  treatment  of  the  middle  ear.     These  colds  are  usually 
caused  and  maintained  by  the  presence  of  chronic  nasal  and  naso- 
pharyngeal   inflammation   or  new  growths.     In   such   instances  little 
progress  can  be  made  toward  the  cure  of  the  aural  affection  until  a  more 
healthful  condition  of  the  upper  air  tract  is  secured.     Head  colds  are 
also  a  symptom  of  vasomotor  rhinitis,  a  nervous  state  in  which  the 
sympathetic  control  of  the  circulation  in  the  mucous  lining  of  the  nose 
is  lost,  resulting  in  oversecretion  and  a  stuffy  feeling  about  the  head — 
a  condition  which  is  exactly  similar  in  its  effects  on  a  discharging  ear 
to  that  just  described  as  resulting  from  new  growths  in  the  nose  or 
nasopharynx. 

In  all  these  cases  it  is  imperative  to  restore  free  nasal  breathing  and 
to  subdue  the  chronic  inflammation  of  the  nose  and  nasopharynx  by 
local  applications  or  surgical  measures  appropriate  to  the  individual 
case,  the  description  of  which  procedures  is  more  fully  given  in  Chapter 
XIX. 

(3)  Local   Medication. — Syringing. — Cleanliness  of  the  suppura- 
ting aural  cavities  is  the  first  consideration  in  the  local  treatment  of  any 
case.    The  maintenance  of  absolute  sterility  of  the  affected  parts  is, 
of  itself,  often  sufficient  treatment,  and  will  cure  many  of  the  milder 
affections.     This  aseptic  state  may  be  secured  by  syringing  or  by 
mopping  the  depths  of  the  auditory  canal  by  means  of  cotton  cylinders 
of  appropriate  size  held  in  the  jaws  of  a  dressing-forceps  (Fig.  203)  or 
by  a  pledget  of  sterile  cotton  on  the  end  of  an  applicator  (Figs.  204 
and  205),  and  of  such  size  as  will  readily  pass  to  the  fundus  of  the  ear. 
Numerous  cleansing  and  antiseptic  solutions  have  been  recommended 
because  of  their  supposed  virtues  in  the  cure  of  the  discharge.      Any 
solution  intended  for  syringing  the  ear  should   possess   the  essential 
qualities  of  sterility  and  non-irritability.      The   first   quality   is   easily 
obtained  by  boiling  and  the  second  by  avoiding  overmedication  with 


CHRONIC    PURULENT    OTITIS    MEDIA 


341 


irritating  antiseptic  substances.  The  simplest  solutions  are  equal  in 
efficiency  to  the  more  complex  and  expensive  ones  and  the  author  has 
secured  as  good  results  from  the  use  of  normal  salt  solution  or  boric 
acid  lotion  as  from  any  other  he  has  tried.  If  the  case  should  seem  to 


FIG.  203. — DRY  METHOD  OF  CLEANSING  THE  EAR. 

A  piece  of  cotton  of  convenient  size  is  folded  into  cylindric  shape,  grasped  near  its  distal  end  in  the  jaws 
of  the  aural  dressing-forceps,  the  auricle  is  retracted  in  the  usual  manner  and  the  cotton  is  inserted  gently  but 
firmly  to  the  bottom  of  the  auditory  canal.  This  procedure  is  repeated  until  the  external  meatus  and  fundus 
of  the  ear  are  thoroughly  dry. 

require  a  stronger  antiseptic,  like  bichlorid  of  mercury,  it  should  not  be 
in  greater  proportion  than  i :  5000,  and  considering  the  short  time  that 
such  a  weak  solution  remains  in  contact  with  the  diseased  tissues,  it  is 


FIG.  204. — AURAL  APPLICATOR. 


clear  that  the  antiseptic  qualities  of  the  drug  will  have  little  if  any  more 
influence  over  the  disease  than  would  the  simplest  non-medicated,  but 
sterile  preparation. 


FIG.  205. — DELICATE  AURAL  APPLICATOR. 

The  frequency  of  cleansing  the  ear  is  of  importance.  If  the  dis- 
charge is  profuse,  foul  smelling,  and  irritant  to  the  tissues  over  which  it 
flows,  it  is  wise  to  cleanse  it  away  frequently  enough  to  neutralize  its 
irritant  qualities  and  to  abate  or  lessen  the  odor.  To  accomplish  this 
may  require  three  or  more  daily  treatments.  In  those  cases  where  the 


342 


THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


discharge  amounts  to  only  a  drop  in  the  twenty-four  hours,  the  small 
amount  of  pus  appears  but  rarely  if  ever  at  the  meatus,  since  it  dries 
into  a  crust  over  and  in  the  vicinity  of  the  perforation.  As  previously 
stated,  a  crust  thus  formed  is  apt  to  be  mistaken  for  hardened  ear  wax. 


FIG.  206. — COMMON  SOFT-RUBBER  AURAL  SYRINGE, 

SUITABLE  FOR  HOME  USE  BY  PATIENT. 

It  is  easily  sterilized. 


FIG.  207. — ALLPORT'S  AURAL  SYRINGE,  WITH  SHIELD. 
No  valves  or  packing  to  become  septic.     Easily 
sterilized ;  efficient  for  nearly  all   purposes  of   aural 
cleansing. 


Syringing  in  such  cases  is  only  indicated  sufficiently  often  to  keep  the 
perforation  free  from  crusting.  There  is  usually  present  necrosis  of 
the  osseous  parts,  and  hence  syringing  can  only  yield  temporary  results. 


FIG.  208. — BLAKE'S  MIDDLE-EAR  SYRINGE,  WITH  ANGULAR  TIP  FOR  CLEANSING  THE  ATTIC. 

When  syringing  any  ear  in  which  there  is  present  a  considerable 
loss  of  the  tympanic  membrane,  and  particularly  if  the  perforation  be 
in  the  location  of  the  stapes,  care  should  be  exercised  at  the  beginning 
not  to  inject  the  fluid  too  forcibly,  since  a  strong  impact  of  the  solution 


CHRONIC    PURULENT   OTITIS    MEDIA 


343 


against  the  inner  tympanic  wall  is  likely  to  cause  the  patient  to  be  giddy 
or  even  to  loose  consciousness  and  fall  in  a  faint.  This  symptom  is  so 
constant  and  pronounced  in  some  individuals  that  it  becomes  impossible 


FIG.  209. — COMMON  AURAL  APPLICATOR  BENT  AT  TIP  TO  NEARLY  A  RIGHT  ANGLE. 

The  bent  portion  should  be  4  or  5  mm.  in  length.     When  armed  with  a  small  tuft  of  cotton,  as  shown,  this 
simple  instrument  is  most  valuable  as  a  carrier  for  medicaments  into  the  attic. 

to  syringe  the  ear,  even  though  the  act  be  performed  with  the  utmost 
gentleness.  The  proper  method  of  cleansing  a  discharging  ear  by 
means  of  syringing  is  shown  in  Fig.  210.  The  common  urethral 


FIG.  210. — METHOD  OF  EFFECTIVELY  SYRINGING  THE  EAR. 

The  patient  supports  the  pus  basin  while  the  operator  retracts  the  auricle  with  one  hand  and  uses  the  syringe 
with  the  other.     Allport's  syringe  in  use. 

syringe  which  is  much  in  use  (Fig.  211),  is  not  an  efficient  instrument 
for  aural  syringing,  and  should  never  be  recommended  for  that  pur- 
pose. 


344  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

The  ear  syringes  in  common  use  for  the  injection  of  fluids  into  the 
external  auditory  canal  (Figs.  206  and  207)  are  not  sufficient  for  cleansing 
the  diseased  areas  when  located  in  the  attic.  In  this  class  of  cases  (see 
Figs.  196  and  197)  a  specially  devised  syringe  (Fig.  208)  or  the  attic 
canula  is  necessary  to  clear  this  portion  of  the  ear  from  the  foul-smelling 
accumulations  of  pus  or  cholcsteatoma  which  are  often  retained  there. 
By  the  use  of  reflected  light,  with  the  speculum  in  position  and  the  auricle 
retracted,  the  delicate  angular  canula  can  be  painlessly  passed  into  the 
middle  ear  and  upward  into  the  attic  behind  the  remnants  of  Shrapnell's 
membrane,  in  which  position  the  cleansing  fluid  can  be  injected  through  it 
with  sufficient  force  to  dislodge  the  decomposing  masses.  After  their 
removal  and  after  the  parts  have  been  dried,  applications  of  any  desired 
medicament,  as  nitrate  of  silver,  can  be  made  to  the  attic  structures  by 


FIG.  211. — COMMON  URETHRAI,  GLASS  SYRINGE. 

An  instrument  much  used  by  the  laity,  some  physicians,  and  even  hospitals,  as  an  ear  syringe.  It  is  shown 
only  to  emphasize  the  fact  that  it  is  useless  as  an  instrument  for  cleansing  the  ear,  especially  if  used  by  the 
patient  himself. 

means  of  a  cotton-tipped  angular  applicator  (Fig.  209),  which  is  passed 
into  the  attic  in  the  same  manner  as  the  irrigating  canula. 

(4)  Mechanical  Removal  of  Accumulated  Septic  Matter. — 
Syringing,  although  thoroughly  done,  is  often  insufficient  to  cleanse 
even  the  external  meatus  or  the  accessible  portions  of  the  middle  ear. 
The  hardened  masses  of  secretion  are  sometimes  so  firmly  attached  to 
the  walls  of  the  auditory  canal  or  to  the  irregularities  of  the  tympanic 
membrane  that  the  injected  fluid  fails  to  pass  around  and  behind  the 
accumulations  with  sufficient  force  to  dislodge  them.  The  parts  should 
therefore  be  occasionally  examined  with  reflected  light  as  the  syringing 
progresses,  and  if  it  be  seen  that  the  injections  have  failed  to  cleanse 
them  thoroughly,  the  process  can  be  hastened  by  gently  removing  the 
offending  matter  with  a  properly  shaped  hook,  ear  hoe,  or  other  instru- 
ment especially  selected  for  the  case. 

The  use  of  peroxid  of  hydrogen  for  the  purpose  of  loosening  and 
thus  facilitating  the  removal  of  hardened  masses  and  of  securing  the 
antiseptic  action  of  the  drug,  is  often  advisable.  It  has  been  charged 
against  this  preparation  that  the  gases  formed  by  its  contact  with  pus 


CHRONIC    PURULENT    OTITIS    MEDIA  345 

are  apt  to  carry  septic  material  into  the  mastoid  antrum  and  cells,  where 
new  foci  of  disease  are  thus  established.  Such  an  occurrence  is  possible, 
and  therefore  certain  considerations  should  govern  the  use  of  the  remedy. 
It  is  most  safely  employed  in  cases  where  the  drum  membrane  is  en- 
tirely or  largely  wanting,  for  in  this  condition  it  is  not  possible  for  gases 
to  form  faster  than  they  escape,  and  hence  the  likelihood  of  infective 
material  being  carried  to  distant  parts  is  scarcely  worthy  of  considera- 
tion. On  the  other  hand,  if  the  perforation  is  small,  the  reverse  is  true, 
and  the  preparation  should  not  be  used. 

If,  as  often  happens  in  the  course  of  a  chronic  discharging  ear,  there 
are  present  crusts  of  dried  secretion  which  form  a  thin  casing  around  the 
walls  of  the  auditory  canal,  and  which  adhere  with  such  tenacity  that  it  is 
difficult  to  dislodge  them,  peroxid  of  hydrogen  is  also  useful  in  facilitating 
their  removal  and  in  subsequently  sterilizing  the  skin  and  hairs  of 
the  external  meatus.  For  this  purpose  the  peroxid  is  most  conveniently 
applied  in  full  strength  by  means  of  a  proper-sized  roll  of  cotton  which 
has  been  wet  in  the  solution  and  is  then  placed  in  the  canal  and  allowed 
to  remain  long  enough — usually  only  a  few  minutes — to  soften  and 
disintegrate  the  accumulations,  after  which  they  may  be  easily  removed 
by  syringing  or  by  the  use  of  the  delicate  dressing-forceps  or  ear-hook. 

(5)  Methods  of  Drying  the  Parts. — After  the  removal  of  every 
particle  of  infective  or  other  material  from  the  external  auditory  canal 
and  middle  ear,  all  these  structures  should  be  thoroughly  dried.  This 
is  accomplished  (a)  by  the  use  of  the  cotton  cylinder  and  an  ear  applicator 
(see  Fig.  203)  used  as  described  for  mopping  the  deeper  parts  of  the 
ear  to  cleanse  them  from  pus.  This  of  itself  is,  however,  not  always 
sufficient  and  must  usually  be  supplemented  by  additional  means,  one 
of  the  best  being: 

(b)  Heated  Air. — Desiccation  by  means  of  the  cotton  mop  can  be 
much  facilitated  and  rendered  more  thorough  and  lasting  by  the  addi- 
tional use  of  dry  and  moderately  heated  air.  The  benefits  derived 
from  the  employment  of  the  hot-air  current  are  particularly  noticeable 
in  cases  where  all  or  a  large  portion  of  the  drum  membrane  is  wanting. 
The  best  method  of  applying  heated  air  is  by  means  of  a  specially  con- 
structed electric  apparatus,  the  temperature  of  the  current  passing  through 
which  can  be  accurately  regulated  (Fig.  212).  The  beneficial  action  of 
hot  air  is,  no  doubt,  due  to  the  fact  that  it  produces  complete  dryness 
of  the  affected  tissues  and  thus  renders  impossible  the  growth  of  bacteria 
so  long  as  the  parts  remain  free  from  moisture.  Although  many  patients 
will  tolerate  a  high  temperature  of  the  air-blast,  the  best  effects  are 
obtained  by  moderate  degrees  of  heat,  since  superheated  air  is  apt  to 


346  THE   PRINCIPLES   AND   PjlACTICE   OF   OTOLOGY 

cause  an  unpleasant  inflammatory  reaction,  and  since  a  milder  degree 
of  heat  will  desiccate  the  parts  equally  well  if  only  a  little  more  time  is 
given  to  its  use. 

It  should  be  stated  that  before  attempts  are  made  to  dry  the  cavities 
of  the  middle  ear  by  any  of  the  preceding  methods  or  by  all  combined, 
that  the  process  will  often  be  much  facilitated  and  the  effects  rendered 
more  lasting  if  Eustachian  catheterization  and  inflation  of  the  middle  ear 
be  first  performed.  A  current  of  air  sufficiently  strong  to  dislodge  any 
pus  or  other  secretion  that  may  fill  the  Eustachian  tube  should  be  blown 
through  the  catheter  which  is  inserted  in  the  usual  position  for  inflating 
the  tympanic  cavity.  The  air  used  for  inflating  the  auditory  tract  will 
prove  more  beneficial  if  it  has  also  been  previously  heated.  In  cases 


FIG.  212. — ELECTRIC  AIR  HEATER. 
A  convenience  for  thoroughly  drying  and  sterilizing  the  tympanic  cavity. 

where  the  perforation  through  the  drum  membrane  is  large  it  is  some- 
times permissible  to  inject  an  antiseptic  wash  through  the  catheter, 
into  the  Eustachian  tube  and  out  through  the  external  meatus,  thus 
cleansing  the  entire  tract  before  applying  the  drying  process  as  above 
advised. 

(c)  Drying  Powders. — Dusting-powders  have,  in  the  past,  been  quite 
universally  employed,  and  often  without  the  slightest  reason.  Hence, 
frequent  disappointment  as  to  results  and  often  danger  to  life  have 
occurred  from  their  indiscriminate  use.  The  rational  employment  of 
powders  in  aural  practise  must,  like  every  other  remedy,  be  based  upon 
an  exact  diagnosis  of  the  condition  which  is  present  in  the  ear  as  well 
as  upon  the  therapeutic  action  of  the  drug  itself.  If  a  large  perforation 
is  known  to  exist  in  the  drum  membrane,  the  moderate  application  of  an 


CHRONIC   PURULENT   OTITIS    MEDIA  347 

antiseptic  drying  powder  to  the  middle-ear  cavity  will,  in  a  majority  of 
cases,  prove  beneficial.  On  the  other  hand,  if  the  rupture  is  small, 
it  is  not  possible  to  blow  the  powder  through  it  so  as  to  reach  the  diseased 
tissues  in  the  middle  ear  beyond,  and  in  attempting  to  do  so  there  is 
danger  of  filling  the  perforation  with  the  powder  and  thus  completely 
blocking  the  drainage.  The  use  of  powder  under  the  latter  circumstances 
could  be  of  value  only  in  so  far  as  it  dries  and  sterilizes  the  external 
meatus.  Since  free  drainage  is  a  first  essential,  under  no  circumstance 
should  any  powder  be  packed  into  the  auditory  canal  in  quantities 
sufficient  to  obstruct  the  outflow  of  pus.  It  seems  scarcely  necessary 
to  add  that  the  middle  ear  and  external  auditory  meatus  should  always 
be  most  thoroughly  cleansed  and  dried  before  the  powder  is  applied. 


FIG.  213. — DsViLBiss  POWDER  BLOWER. 

The  construction  of  this  instalment  is  such  that  only  the  most  finely  comminuted  powder  may  be  blown  into 

the  ear. 

A  long  list  of  powders  has  been  recommended  by  various  authors 
for  aural  use,  but  none  is  better  than  finely  powdered  boric  acid  if 
only  the  desiccating  effect  of  the  drug  is  desired.  By  the  absorptive 
properties  of  the  powder  the  diseased  fluids  are  so  taken  up  that  germ 
life  is  for  the  time,  at  least,  inhibited  or  completely  arrested.  Hence, 
after  a  discharging  ear  is  cleansed  of  its  septic  contents,  has  been  thor- 
oughly dried  by  mopping  with  cotton  and  the  application  of  hot  air, 
the  insufflation  of  a  drying  powder  will  continue  the  purifying  and 
inhibiting  process  in  many  cases  for  a  very  considerable  length  of  time. 

The  construction  of  the  powder-blower  to  be  used  in  aural  practise 
is  of  much  importance.  One  with  a  receptacle  which  permits  the 
passage  of  an  indirect  air  current  should  be  employed,  since  by  such 


348 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


an  instrument  only  is  it  possible  to  distribute  the  powder   evenly   and 
in  finely  divided  portions  over  the  diseased  areas  (Fig.  213). 

(d)  The  Gauze  Wick. — When  large  portions  of  the  tympanic  mem- 
brane have  been  lost  and  there  are  present  neither  polypi  nor  areas  of 
carious  bone,  the  dry  and  sterile  state  of  the  drum  cavity  which  has  been 
secured  by  the  foregoing  treatment  may  be  greatly  prolonged  by  the 
insertion  of  a  sterile  or  medicated  strip  of  dry  gauze  to  the  fundus  of  the 
ear  in  such  a  manner  that  the  distal  end  lies  in  direct  contact  with  as 
much  of  the  diseased  portion  of  the  middle  ear  as  possible.  The  strips 
should  be  f  inch  wide  and  2\  or  3  inches  long.  They  should  be 
specially  prepared  and  in  quantity,  free  from  loose  ravelings,  sterilized, 
and  kept  in  any  suitable  jar,  from  which  one  is  withdrawn  by  the  aural 


FIG.  214. — HARTMANN  DRESSING-FORCEPS. 

forceps  at  the  instant  it  is  to  be  used.  The  insertion  is  readily  and  pain- 
lessly accomplished  by  folding  the  distal  end  of  the  strip  into  cylindric 
shape,  grasping  it  \  inch  from  the  extremity  between  the  jaws  of  a  delicate 
dressing-forceps  (Fig.  214),  when,  with  the  auricle  strongly  retracted,  the 
gauze  is  carried  at  once  to  the  desired  position.  It  is  never  wise  to  pack 
the  ear  tightly  with  such  a  strip,  since  packing  may  not  only  create  dis- 
comfort to  the  patient  but  may  also  hinder  instead  of  facilitate  the 
drainage.  The  beneficial  effects  of  the  "wick  treatment"  are,  no  doubt, 
brought  about  by  the  provision  for  the  absorption  of  the  pus  as  fast 
as  it  is  secreted  and  by  the  stimulating  depletion  to  which  its  presence 
gives  rise.  The  gauze  dressing  must  be  changed  as  often  as  it  be- 
comes saturated  with  the  fluid  absorbed  from  the  deeper  parts,  which 


CHRONIC    PURULENT    OTITIS   MEDIA  349 

may  occur  several  times  daily  or  only  once  in  several  days.  The  above 
methods  of  cleansing  and  drying  will,  if  thoroughly  and  correctly  car- 
ried out,  often  prove  sufficient  to  bring  about  a  speedy  cure  of  the 
milder  and  sometimes  even  of  the  more  severe  and  troublesome  cases. 

(6)  Ear  Drops. — Experience  has  taught,  however,  that  some  in- 
dividual cases  of  aural  discharge  are  not  successfully  managed  by  the 
dry  treatment,  owing  perhaps  to  an  idiosyncrasy  on  the  part  of  the 
patient  toward  that  form  of  medication.  In  such  cases  it  can  be  deter- 
mined only  by  trial  that  the  wick  method  is  useless  or  harmful.  There 
are  also  those  in  which  the  pathologic  rinding  at  the  time  of  the  first 
examination  will  be  such  that  it  will  be  deemed  wTiser  to  instil  some 
kind  of  ear  drops  from  the  beginning.  If  there  is  uncertainty  as  to 
whether  the  one  or  the  other  method  should  be  employed,  it  is  most 
satisfactory  in  the  majority  of  cases  to  choose  the  dry  treatment,  at  least 
until  its  inefficiency  or  harmful  nature  is  demonstrated. 

If  the  drum  membrane  has  been  largely  destroyed  and  exposes  a 
granular  mucous  lining  of  the  middle  ear;  if  the  pus  has  a  foul  odor  or 
there  are  present  masses  of  cholesteatoma,  a  solution  of  boric  acid 
in  alcohol  in  the  proportion  of  gr.  xx  of  the  former  to  §j  of  the  latter  is 
highly  efficacious.  After  having  cleansed  and  dried  the  cavity  as 
previously  directed,  a  few  drops  of  this  preparation  are  instilled  into  the 
ear  and  allowed  to  remain  at  least  five  minutes.  The  solution  shrivels 
the  granulations,  is  antiseptic  and  astringent,  and  usually  lessens  both 
the  odor  and  the  amount  of  the  discharge.  When  the  odor  is  un- 
usually offensive  greater  benefit  may  be  derived  from  the  addition  of 
^  gr.  of  mercury  bichlorid  to  each  ounce  of  the  above  solution.  If 
used  in  the  strength  here  advised  considerable  pain  may  at  first  be 
produced,  and  the  solution  should  therefore  be  diluted.  As  the  tissues 
harden  from  its  continued  employment  they  become  less  sensitive, 
and  in  due  time  the  preparation  may  be  used  in  its  full  strength  without 
discomfort  to  the  patient. 

During  the  employment  of  any  liquid  medication  in  aural  practise 
the  patient  should  incline  the  head  far  to  one  side  or,  preferably,  should 
lie  upon  a  lounge  with  the  affected  ear  uppermost.  All  ear  drops  should 
be  warmed  before  using.  After  instillation  the  auricle  should  be  strongly 
retracted  to  the  same  position  in  which  it  is  drawn  for  insertion  of  the 
aural  speculum  and  the  use  of  reflected  light — namely,  upward  and 
backward — until  the  auditory  canal  is  straightened.  Such  a  movement 
separates  the  walls  of  the  external  meatus  and  possibly  opens  to  some 
extent  the  perforated  tympanic  membrane,  thus  more  freely  admitting 
the  medicament  into  the  middle-ear  cavity.  The  fluid  is  then  driven 


350  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

deeply  into  the  ear  and  around  the  diseased  tissues  by  placing  a  finger 
upon  the  tragus  and  pressing  this  structure  rapidly  and  repeatedly  into 
and  out  of  the  concha.  Siegle's  otoscope  with  the  bag  attached  can 
also  be  efficiently  used  for  forcing  the  ear  drops  deeply  into  all  the 
diseased  aural  recesses.  When  this  instrument  is  employed  for  the 
above  purpose,  its  speculum  end  is  inserted,  air  tight,  into  the  ex- 
ternal meatus,  and,  beginning  with  the  bag  filled  with  air,  compression 
is  gently  made  so  as  to  drive  a  column  of  air  inward,  and  before  it  the 
drops  intended  for  the  medication.  It  will  be  seen  that  this  use  of 
Siegle's  otoscope  is  exactly  the  reverse  of  that  employed  for  massaging 
the  drum  membrane  where  adhesions,  but  no  perforation,  exist,  in  which 
latter  method  suction  only  is  used. 

Solutions  of  silver  nitrate  are  most  beneficial  in  cases  where  the 
mucous  lining  of  the  drum  cavity  is  chronically  inflamed,  thickened,  and 
covered  with  mucopurulent  discharge.  The  strength  of  this  preparation 
should  not  exceed  gr.  v  to  3]  in  the  beginning,  since  the  reaction  from 
stronger  solutions  is  sometimes  severe.  The  strength  should,  however, 
be  increased  as  toleration  is  established  and  the  necessities  of  the  case 
demand,  until  in  some  instances  gr.  xc  or  cxx.  to  5J  are  most  satis- 
factorily employed.1 

In  order  to  obtain  the  full  effect  of  any  given  strength  of  nitrate  of 
silver  certain  precautions  in  the  method  of  its  employment  are  necessary. 
This  silver  salt  is  exceedingly  sensitive  to  precipitation;  therefore  its 
solutions  should  always  be  prepared  with  distilled  water.  The  preceding 
ear  washes  should  be  such  as  are  not  incompatible  with  the  silver  com- 
pound, but  if  any  such  have  just  been  used,  any  remaining  portion  of 
the  same  should  be  immediately  cleansed  away  by  syringing  the  ear 
with  distilled  water.  The  ear  should  also  be  previously  dried  with  the 
usual  thoroughness  in  order  that  the  silver  solution  may  not  be  so  diluted 
by  secretions  or  by  a  quantity  of  the  wash  remaining  at  the  bottom  of 
the  canal  which  is  sufficient  to  render  the  effect  of  the  silver  impotent 
or  inert.  These  suggestions  may  seem  trivial  and  unnecessary,  but  are 
made  because  frequent  failure  to  cure  will  result  from  neglect  of  their 
observance. 

In  the  very  mild  cases,  and  such  as  are  often  seen  in  children  where 
the  perforation  is  small  and  posterior  to  the  umbo,  and  in  whom  the 

*D.  A.  Kuyk,  Transactions  Sec.  Otol.  and  Laryngol.,  A.M.  A.,  1903,  advocates  the 
employment  in  the  beginning  of  a  solution  of  silver  nitrate  of  the  strength  of  30  gr. 
to  the  ounce.  This,  he  states,  should  be  forced  into  the  remotest  recesses  of  the  middle 
ear  by  means  of  Siegle's  otoscope,  the  treatment  being  given  every  second  day.  If 
after  a  period  of  two  weeks  there  is  no  improvement,  a  solution  of  60  gr.  to  the  ounce 
is  substituted,  and  this  is  gradually  increased  until  120  gr.  to  the  ounce  are  employed. 


CHRONIC    PURULENT   OTITIS    MEDIA  351 

discharge  is  stringy,  the  following  lotion  has  been  much  and  satisfactorily 
used :  * 

R.  Zinc  sulphate,  gr.  v; 

Glycerin,  3J; 

Saturated  sol.  boric  acid,  q.  s.  gj. — M. 

Sig.  A  few  drops  of  this  solution  may  be  instilled  two  or  three  times  a  day  after  drying 
and  cleansing  the  ear. 

(7)  Caustics. — Granulations  or  polypi  when  present  should  at  once 
be  removed  or  destroyed.      If  small,  each  individual  growth  may  be 
touched  with  a  bead  of  chromic  acid  or  of  nitrate  of  silver  which  has  been 
fused  on  the  end  of  a  delicate  aural  applicator  (see  Fig.  209).     Chromic 
acid  is  much  the  more  potent  remedy,  and  should  be  used  in  the  middle 
ear  with  the  greatest  care  lest  severe  inflammatory  reaction  be  set   up 
and  unnecessary  damage  be  thereby  caused  to  the  already  crippled 
hearing  organ.      If  applied  to  a  wet  surface  any  caustic  will  spread  and 
do  mischief  to  adjoining  parts.     Therefore  the  growth  to  be  touched 
by  the  destructive  agent  should  be  prepared  for  the  caustic  application 
by  first  cleansing  and  then  thoroughly  drying  the  entire  area  to  be 
treated  according  to  the  methods  already  outlined.     The  part  which 
is  to  be  destroyed  must  also  be  illuminated  and  in  full  view  of  the 
operator  when  the  caustic  is  applied.      More  than  one  application  is 
usually  necessary,  a  period  of  three  or  four  days  intervening  between 
treatments. 

The  destruction  of  granulations  and  small  polypi  may  also  be  ac- 
complished by  the  use  of  the  electrocautery,  a  delicate  sharp-pointed 
electrode  being  used  for  this  purpose.  This  method,  however,  is  safe 
only  in  the  hands  of  the  most  skilful  and  under  the  most  favorable 
circumstances  as  to  location  and  illumination  of  the  part  to  be  cauterized. 
The  beginner  should,  therefore,  use  milder  means,  even  if  longer  time 
is  required  to  accomplish  the  same  end. 

(8)  Cocain  Anesthesia. — The  use  of  cocain  to  produce  local  anes- 
thesia during  the  action  of  caustics,  as  well  as  of  many  operative  proced- 
ures within  the  middle  ear,  is  highly  essential  to  successful  and  painless 
results.     The  proper  method  of  its  employment  in  the  ear  is,  therefore, 
important.     If  the  operation  is  of  such  nature  as  to  cause  hemorrhage 
in  sufficient  quantity  to  obstruct  the  view  of  the  operative  field  and 
thus  to  hinder  the  progress  of  the  work,  the  cocain  crystals  may  be  dis- 
solved in  the  full  strength  solution  of  adrenalin  chlorid,  since  this  com- 
bination will  act  equally  well  to  benumb  the  parts  and  at  the  same  time 
to  exsanguinate  them. . 

1  Bacon,  Manual  o)  Otology,  1898. 


352  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

When  large  areas  of  mucous  membrane  are  exposed,  as  in  cases 
where  the  drum  membrane  is  largely  or  wholly  wanting,  cocain  solutions 
are  rapidly  absorbed  and  hence  unpleasant  or  even  dangerous  symptoms 
may  develop  should  the  drug  be  carelessly  employed.  Cocain  is  sensi- 
tive to  precipitation  by  alkaline  and  other  solutions  which  are  often 
used  for  cleansing  the  ear.  Hence,  if  such  have  just  previously  been 
used,  any  excess  of  the  solution  which  may  have  remained  in  the  tympanic 
cavity  should  be  washed  away  with  some  compatible  preparation  like 
normal  salt  or  boric  acid  solution  before  the  application  of  the  cocain 
is  made,  since  otherwise  the  anesthetic  effect  of  the  latter  drug  would 
be  greatly  lessened  or  altogether  lost.  The  parts  to  be  anesthetized 
should  also  be  dried,  for  if  irrigating  solutions  or  secretions  remain  in 
the  tympanum,  the  cocain  solution  will  be  diluted,  and  in  proportion  to 
the  amount  of  the  dilution,  its  desired  action  will  be  lost;  5  drops 
of  a  10  or  15  per  cent,  solution  of  cocain,  either  in  adrenalin  chlorid 
or  in  normal  salt  solution,  according  to  the  effect  desired,  may  be  dropped 
into  the  ear  and  allowed  to  remain  from  five  to  ten  minutes,  after 
which  any  excess  is  mopped  a\vay  with  sterile  cotton.  If  the  parts 
are  still  sensitive  to  the  manipulation  of  the  probe  they  may  be  touched 
with  a  cotton-tipped  applicator  which  has  been  dipped  into  a  stronger 
solution  of  cocain. 

When  the  tympanic  cavity  is  highly  sensitive  the  most  satisfactory 
anesthesia  is  obtained  by  the  direct  application  of  pure  cocain  crystals 
to  the  operative  field;  i  gr.  of  the  powdered  crystals  having  been 
placed  upon  a  glass  plate,  and  a  pledget  of  cotton  wound  about  the  end 
of  an  applicator,  the  cotton  is  first  dipped  into  a  solution  of  cocain  and 
then  immediately  rolled  in  the  powder  until  a  sufficient  amount  adheres. 
A  known  quantity  of  the  drug  can  thus  be  readily  carried  to  the  desired 
spot,  the  complete  insensibility  of  which  is  thereby  speedily  and  safely 
accomplished,  since  by  this  method  there  is  no  spreading  of  the  cocain 
and  only  a  small  area  of  mucous  membrane  can  absorb  the  same;  there 
is,  therefore,  less  danger  from  toxic  effects  than  when  weak  solutions  are 
more  generously  employed.  It  should  of  course  be  remembered  that 
no  anesthesia  can  be  obtained  from  the  instillation  of  cocain  solutions 
into  the  ear  unless  there  is  present  in  the  drum  membrane  a  perfora- 
tion of  sufficient  size  to  admit  the  drug  into  the  tympanic  cavity.  If, 
therefore,  the  perforation  is  quite  small  it  will  be  necessary  to  inject 
the  cocain  solution  into  the  tympanic  cavity  by  means  of  a  small  pipet, 
the  canula  of  which  is  inserted  directly  through  the  perforation. 


CHAPTER  XXVIII 
CHRONIC    PURULENT    OTITIS    MEDIA    (Continued) 

THE   SURGICAL    TREATMENT 

THE  medicinal  treatment  of  chronic  otorrhea  which  was  outlined  in 
the  preceding  chapter  will,  if  systematically  and  intelligently  carried 
out,  cure  a  large  percentage  of  all  cases  of  this  character.  Those  cases 
in  which  there  has  been  destruction  of  the  deeper  tissues  and  in  which 
caries  or  necrosis  of  the  bony  parts  has  taken  place  will,  however,  seldom 
yield  to  such  mild  measures.  The  accurate  diagnosis  that  should  be 
made  prior  to  the  institution  of  any  treatment  will  at  that  time  indicate 
the  degree  of  success  or  failure  that  is  likely  to  result  from  mere  antiseptic 
cleansing,  local  medication,  or  general  therapeutics.  Hence,  when  it 
is  definitely  determined  that  the  osseous  structures  have  already  been 
attacked  by  the  aural  disease,  and  that  there  are  present  areas  of  uncov- 
ered bone,  it  is  unwise  to  continue  indefinitely  with  unaided  medicinal 
measures.  Therefore,  after  such  means  have  been  faithfully  and 
carefully  applied  for  a  few  weeks,  if  the  aural  discharge  is  but  slightly 
or  not  at  all  lessened,  and  if  the  foul  odor  of  the  discharge  continues 
despite  the  treatment;  or  if  it  should  return  immediately  after  treatment 
is  withheld,  there  is  slight  prospect  of  alleviation  or  cure  of  the  disease 
from  their  further  use.  In  all  these  cases  experience  has  proved  that 
surgery  is  the  most  conservative  and  logical  means  of  treatment,  and 
that  its  employment  in  this  class  of  aural  ailments  is  as  rational  and  is 
followed  by  as  satisfactory  results  as  when  applied  to  diseases  of  other 
regions  of  the  body. 

The  surgical  management  of  this  disease  can  best  be  considered  in 
two  divisions: 

First,  the  surgery  of  the  middle  ear,  attic,  and  parts  adjacent,  which 
are  accessible  to  instrumentation  through  the  external  auditory  meatus, 
and  may  be  designated  intratympanic  surgery. 

Second,  that  which  embraces  all  the  tissues  in  and  adjoining  the  ear 
which  are  likely  to  become  diseased  through  extension  from  the  tym- 
panum. This  latter  includes  the  intracranial  complications.  This 
division  is  fully  included  in  the  radical  mastoid  operation  and  will  be 
considered  in  a  subsequent  chapter. 

23  353 


354  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

INTRATYM  PANIC    SURGERY 

This  title  should  include  a  discussion  of  all  operative  procedures 
upon  the  drum  membrane  and  middle  ear  that  are  performed  for  the 
purpose  of  securing  better  drainage,  for  arresting  the  discharges,  or  for 
improving  the  impaired  hearing  by  the  division  of  adhesions  or  other 
obstructions  to  the  transmission  of  sound.  Sufficient  mention  has, 
however,  already  been  made  of  the  milder  surgical  procedures  in  the 
chapters  dealing  with  the  treatment  of  acute  and  chronic  aural  inflamma- 
tions and  suppurations,  some  of  which  operations  have  been  discarded 
because  found  to  be  of  little  value.  The  author  believes  that  the  full 
description  of  such  operations  as  paracentesis,  which  as  a  means  of 
treatment  are  usually  performed  in  conjunction  with  the  use  of  important 
medicinal  measures,  is  best  given  in  the  chapters  dealing  with  the 
treatment  of  the  disease  requiring  the  operation.  Intratympanic 
surgery,  however,  as  related  to  the  management  and  cure  of  chronic 


FIG.  215. — BLAKE'S  POLYPUS  SNARE. 

aural  suppurations,  is  so  distinctly  a  method  apart  from  medicinal  aid, 
that  it  should  receive  the  emphasis  and  dignity  afforded  by  an  entirely 
separate  discussion. 

Removal  of  Polypi  by  Curet  or  Snare. — The  aural  snare  (Fig. 
215)  and  curet  are  the  proper  instruments  to  use  for  the  removal  of 
all  polypi  too  large  to  be  destroyed  by  cauterization.  Generally  speaking, 
the  curet  is  best  sufted  for  the  removal  of  the  smaller  tumors,  while  the 
snare  is  preferred  for  the  larger  ones.  Several  sizes  of  the  curet  (Fig.  216, 
a,  b,  c)  are  necessary  to  fit  the  different  sized  tumors.  Each  should  have 
a  thin,  sharp-edged  ring  knife.  Most  aural  curets  on  the  market  have  the 
serious  fault  of  being  so  broad  at  the  ring  portion  that  when  inserted 
to  the  fundus  this  part  of  the  instrument  covers  the  polypus  to  such  an 
extent  that  it  is  often  difficult  for  the  operator  to  see  the  growth  with 


CHRONIC    PURULENT   OTITIS    MEDIA 


355 


sufficient  clearness  to  enable  him  to  perform  the  ablation  as  easily  and 
painlessly  as  could  be  done  with  a  properly  constructed  instrument.  In 
using  an  instrument  with  a  narrow,  thin  ring  (Fig.  216,  C)  and  a  delicate 
shank  the  operator  is  able  to  observe  in  most  instances  the  position 
of  the  ring  at  each  step  of  the  manipulation.  Little  difficulty  is,  there- 
fore, experienced  in  passing  the  ring  over  the  growth  to  its  base,  at  which 


0 


B 


D 


FIG.  216. — DIFFERENT  SIZES  OF  AURAL  CDRETS  FOR  USE  IN  REMOVAL  OF  GRANULATIONS  AND  SMALL  POLYPI 

FROM  THE  TYMPANIC  CAVITY. 

Note  thin,  fenestrated  blades.     Curets  commonly  sold  have  blades  so  thick  as  to  render  use  of  instruments 

difficult  or  impossible. 

time  the  operator  makes  firm  pressure  upon  the  handle  in  the  direction 
of  the  attachment  of  the  polypus  and  then  quickly  withdraws  the 
instrument,  thus  severing  and  bringing  the  polypus  away  with  the  curet. 
If  more  than  one  polypus  is  present,  the  remaining  ones  may  be  removed 
in  a  similar  manner  and  at  the  same  sitting,  provided  the  hemorrhage 
is  not  so  profuse  as  to  interfere  with  further  work. 

An  aural  snare  (Fig.  215)  should  be  of  delicate  construction,  since 


356  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

little  strength  is  required  in  any  of  its  parts.  The  canula  should  be  of 
the  smallest  diameter  that  will  admit  the  small  wire  used  for  the  ecrase- 
ment.  If  the  canula  is  bulky  the  view  of  the  deeper  parts  will  be  so 
obstructed  during  its  use  that  precision  in  encircling  the  polypus  with 
the  wire  loop  will  be  interfered  with  to  an  extent  that  may  result  in  an 
incomplete  operation. 

Having  previously  determined  the  site  of  its  attachment  by  the  use 
of  the  examining  probe,  a  large  thin-walled  speculum  is  introduced,  the 
auricle  is  retracted,  and  the  growth  well  illuminated.  A  wire  loop  of 
appropriate  size  is  inserted  and  passed  along  the  wall  of  the  meatus 
opposite  to  that  from  which  the  polypus  springs,  then  over  and  around 
the  growth,  and  finally  to  its  base,  by  the  gentle  insinuation  of  the 
instrument  in  such  a  manner  and  direction  as  may  be  indicated  by  the 
position  and  size  of  the  tumor.  When  the  wire  loop  is  believed  to  have 
reached  the  base  of  the  growth  it  is  tightened  until  a  firm  grasp  is 
obtained,  when  it  is  permissible,  provided  it  does  not  arise  from  the 
tympanic  roof,  very  gently  to  jerk  the  instrument  and,  by  so  doing, 
pull  the  polypus  away  at  its  deepest  point  of  attachment.  Should 
the  polypi  spring  from  the  necrosing  tegmen  tympani  it  is  entirely 
possible  to  expose  the  dura  mater  during  their  complete  removal, 
and  thus  to  open  a  fresh  channel  for  intracranial  infection.  Hence, 
meningitis  is  a  possible  early  sequence  of  the  removal  of  aural  polypi 
from  the  attic,  and  a  certain  amount  of  care  should,  therefore,be  exercised 
in  the  performance  of  this  operation.  If  diseased  bone  can  be  detected 
in  the  midst  of  polypi  which  spring  from  the  tegmen  tympani,  it  is  safer 
to  perform  the  radical  mastoid  operation  than  to  rely  upon  intratympanic 
measures  directed  toward  the  removal  of  the  disease. 

After  any  remaining  growths  have  likewise  been  removed,  the  blood 
is  dried  from  the  meatus  and  a  strip  of  sterile  gauze  is  inserted  to  its 
bottom.  But  little  pain  either  accompanies  or  follows  these  operations, 
and  the  wounded  areas  usually  heal  rapidly.  If  any  remnant  of  the 
polypus  is  left  behind  by  the  snare  or  curet,  the  same  should  be  touched 
with  chromic  acid  once  each  week  until  it  is  completely  destroyed. 
Following  the  removal  of  polypi  the  probe  should  be  used  to  detect, 
if  possible,  the  nature  of  the  tissue  from  which  they  grew.  If  found 
to  have  sprung  from  the  hypertrophied  mucous  membrane  the  polypi 
are  not  likely  to  return;  whereas,  if  uncovered  bone  is  found  at  the 
seat  of  their  origin,  a  speedy  recurrence  may  be  expected.  In  any  case, 
the  patient  should  be  informed  that  the  polypi  are  only  a  symptom  of  the 
aural  affection,  and  that,  therefore,  their  removal  is  only  one  step,  and 
often  the  least  important  one,  in  the  cure  of  the  suppurative  disease. 


CHRONIC   PURULENT   OTITIS    MEDIA  357 

Ossiculectomy  and  Curetage  of  the  Middle  Ear  and  Attic 
in  the  Treatment  of  Chronic  Suppurative  Aural  Diseases. — When 
the  violence  of  the  acute  disease,  together  with  the  resulting  chronic 
suppuration,  has  caused  the  death  of  a  portion  or  all  of  one  or  more 
ossicles  (see  Fig.  202)  the  necrosed  part  becomes  in  effect  a  foreign  body 
in  the  tympanic  cavity,  and  its  presence  sets  up  an  additional  irritation. 
Good  surgery  indicates  the  early  removal  of  such  an  ossicle,  together 
with  the  polypi,  granulations,  or  thickened  mucous  membrane  in  which 
it  is  usually  imbedded. 

Ossiculectomy  is  not  indicated  if  there  is  present,  in  addition  to  the 
diseased  ossicle,  an  extensive  implication  of  the  osseous  walls  of  the  more 
inaccessible  parts  of  the  attic,  or  if  a  suppurative  process  is  already 
well  established  in  the  mastoid  antrum  as  well  as  in  the  middle  ear; 
because  in  such  cases  it  is  obvious  that  removal  of  the  accessible  portions 
of  the  disease  could  only  improve  but  not  cure  the  aural  ailment.  Ossic- 
ulectomy is  also  contra-indicated  in  cases  where  the  lumen  of  the  external 
auditory  meatus  has  become  greatly  narrowed  as  a  result  of  chronic 
eczematous  or  other  inflammatory  thickening  of  its  walls  or  from  the 
projection  into  it  of  an  osteomatous  or  other  growth.  Under  such 
circumstances  it  is  impossible  to  see  the  parts  to  be  operated  upon  with 
sufficient  clearness  or  to  manipulate  the  instruments  within  the  limited 
space  with  that  degree  of  precision  which  should  characterize  intra- 
tympanic  surgery.  The  radical  mastoid  operation  is  better  suited  to 
such  cases,  since  by  it  the  disease  can  be  more  intelligently  and  thor- 
oughly removed  and  the  results  are  certain  to  be  more  satisfactory. 

If,  however,  the  previous  examination  of  the  ear  has  made  it  fairly 
certain  that  the  disease  is  limited  to  the  structures  of  the  middle  ear, 
Ossiculectomy  with  thorough  curetage  of  the  hypertrophied  mucous 
membrane  will  effect  a  cure  in  a  large  proportion  of  cases. 

The  operation  of  Ossiculectomy  may  be  performed  either  with  or 
without  a  general  anesthetic.  Determination  of  this  point  must  be 
based  upon  whether  or  not  the  patient  possesses  that  amount  of  self- 
control  necessary  to  endure  the  moderate  pain  attendant,  and  upon  the 
extent  of  the  diseased  tissues  to  be  removed.  The  author  has,  in  selected 
cases,  frequently  removed  the  malleus  and  incus,  chipped  away  a  con- 
siderable portion  of  the  external  attic  wall,  and  accomplished  an  en- 
tirely satisfactory  curetment  of  the  thickened  mucous  membrane 
under  the  local  cocain  anesthesia.  When  the  perforation  in  the  drum 
membrane  is  large,  local  anesthesia  may  be  secured  as  described  on 
p.  351.  If  the  tympanic  opening  is  small,  the  solution  may  be  dropped 
through  it  into  the  cavum  tympani  by  means  of  a  delicate  ear  pipet. 


358  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

The  occurrence  of  even  slight  bleeding  at  any  stage  of  the  operation 
will  so  hinder  the  progress  as  to  make  the  operative  work  both  uncertain 
and  unsafe.  The  use  of  adrenalin  chlorid  in  i :  1000  solution  is,  there- 
fore, of  the  greatest  assistance  since  it  produces  a  nearly  bloodless  field. 
For  the  reason  that  chloroform  causes  less  venous  stagnation  and 
therefore  less  bleeding  than  ether,  the  former  anesthetic  should  be  the 
choice  when  general  narcosis  is  desirable. 

Aside  from  the  position  of  the  patient,  which  should  be  prone  under 
general  anesthesia  and  upright  when  cocain  is  used,  the  steps  of  the 
operation  are  the  same  in  both.  The  preparation  of  the  ear,  hands,  and 
instruments  should  be  in  accordance  with  the  strictest  interpretation 
of  the  modern  methods  of  asepsis.  The  sitting  posture  of  the  patient 
is  somewhat  advantageous  from  the  fact  that  when  the  patient  is  erect 
the  operator  sees  the  field  of  operation  in  that  position  with  which  he 
is  most  familiar;  whereas,  with  the  patient  lying  down,  it  becomes  neces- 
sary to  bear  the  changed  position  constantly  in  mind.  In  addition  to 
the  instruments  required,  a  half -gross  of  sterile  cotton  mops  especially 
prepared  should  be  at  hand.  These  are  made  by  twisting  appropriate 
sized  pledgets  of  cotton  about  one  end  of  long,  smooth  toothpicks.  Each 
mop  is  rapidly  used  when  needed  to  absorb  secretions  or  blood  and 
is  then  thrown  away.  A  darkened  room  and  a  good  source  of  light 
are  essential.  The  electric  head  light  shown  in  Fig.  89  is  satisfactory, 
but  an  ordinary  head  mirror  can  be  used  equally  as  well.  The  largest 
ear  speculum  that  can  be  inserted  into  the  meatus  ought  always  to  be 
selected,  since  as  much  space  as  possible  should  be  provided  through 
which  to  see  the  field  and  in  which  to  manipulate  the  instruments 
necessary  for  the  performance  of  the  operation. 

The  first  step  consists  in  liberating  any  remaining  portion  of  the 
drum  membrane  from  its  attachment  to  the  malleus.  In  many  cases 
this  remnant  of  membrane,  as  well  as  the  mucosa  of  the  middle  ear, 
is  greatly  thickened  and  highly  vascular,  in  which  condition  sufficient 
bleeding  will  be  caused,  if  the  greatest  care  be  not  taken  in  making  the 
necessary  incisions,  greatly  to  hinder  the  progress  of  the  work.  The 
knife  shown  in  Fig.  141  is  inserted  through  the  membrane  i  mm.  from 
the  annulus  tympanicus,  at  a  point  on  a  level  with  and  posterior  to  the 
umbo.  The  incision  is  carried  rapidly  upward  to  the  posterior  fold, 
then  along  the  lower  margin  of  this  fold  to  the  short  process,  after 
which  it  follows  the  manubrium  into  the  perforation.  On  account 
of  the  troublesome  hemorrhage  it  would  cause,  much  caution  should 
be  exercised  not  to  insert  the  knife  too  deeply  and  thereby  wound  the 
mucous  membrane  covering  the  inner  wall  of  the  drum  cavity.  The 


CHRONIC   PURULENT   OTITIS    MEDIA  359 

anterior  attachments  of  the  drum  membrane  to  the  malleus  handle  are 
likewise  incised,  after  which  the  portions  so  detached  can  be  turned 
down  or  entirely  removed.  Any  tendency  to  bleed  as  a  result  of  the 
foregoing  procedure  is  now  checked  by  the  use  of  the  cotton  mops  or 
cylinders  of  cotton,  applied  accurately  and  under  moderate  pressure 
to  the  bottom  of  the  canal,  where  they  are  allowed  to  remain  for  a 
moment.  The  fundus  of  the  ear  is  thus  dried  so  that  definite  inspection 
of  the  work  is  again  possible. 

Disarticulation  of  the  incudostapedial  joint  and  severance  of  the 
tendon  of  the  stapedius  muscle  constitutes  the  second  step.  The  head 
of  the  patient  must  now  be  placed  in  the  position  most  favorable  for 
the  inspection  of  this  joint  (see  Fig.  198).  The  angular  knife  shown  in 
Fig.  217  is  passed  just  inward  to  the  long  process  of  the  incus  and  in 


FIG.  217. — ANGULAR  KNIFE. 

front  of  the  joint  to  be  severed,  when,  by  rotation  of  the  knife-handle, 
the  blade  of  the  instrument  slides  along  the  inner  surface  of  the  long 
process  of  the  incus  till  the  joint  is  reached  and  disarticulated. 

The  instrument  is  then  inserted  posterior  to  the  head  of  the  stapes 
in  order  to  detach  the  stapedius  muscle  from  the  stirrup.  Since  any 
violence  to  the  stapes  may  not  only  produce  a  more  profound  deafness 
but  may  also  cause  distressing  dizziness  or  even  permit  septic  material 
to  enter  the  vestibule,  it  is  highly  important  that  no  unskilful  or  rude 
manipulation  be  made  when  operating  on  this  or  adjacent  structures. 


FIG.  218. — BLUNT-POINTED  KNIFE. 

It  is  largely  for  the  protection  of  the  stapes  that  it  is  advisable  com- 
pletely to  separate  the  incus  from  the  stapes  before  any  attempt  is 
made  to  extract  either  the  malleus  or  incus. 

Any  hemorrhage  that  may  have  been  set  up  is  again  checked  in  the 
former  manner,  after  which  the  third  step,  the  detachment  of  the  liga- 
mentous  supports  of  the  malleus,  is  accomplished.  The  blunt-pointed 
knife  (Fig.  218)  is  selected  for  this  purpose  and  passed  under  the  posterior 
fold  into  the  tympanic  cavity  at  a  point  immediately  behind  the  short 
process  of  the  malleus.  With  the  cutting  edge  turned  upward  the 
instrument  is  carried  firmly  into  the  tissues  above,  while,  at  the  same 
time,  the  handle  of  the  knife  is  depressed.  This  procedure  is  repeated 
by  making  an  upward  incision  through  the  anterior  fold  just  in  front 


360  THE   PRINCIPLES   AND   PRACTICE    OF   OTOLOGY 

of  the  short  process.  The  anterior  and  posterior  ligaments  are  thus 
severed  and  the  malleus  is  detached  everywhere  except  from  the  sus- 
pensary  and  annular  ligaments,  each  of  which  readily  yields  when 
traction  is  applied  in  removing  the  malleus.  At  this  juncture  it  is  once 
more  necessary  to  deal  with  some  bleeding,  after  which  the  malleus  is 
seized  at  the  uppermost  part  of  the  manubrium  by  a  delicate  but  strong 
forceps  (Fig.  219),  and  traction  is  made,  first  downward  until  the  bone 
is  dislodged  from  the  attic,  and  then  outward  through  the  meatus. 


FIG.  219. — McKAY's  FORCEPS,  WITH  TEETH  GROUND  SHORT. 

The  incus,  if  present,  is  next  extracted.  The  preceding  manipula- 
tions may  have  displaced  this  ossicle  forward,  backward,  or  downward 
into  a  position  which  will  require  searching  to  discover  it.  For  this 
purpose  the  incus  hook  (Fig.  220)  is  inserted  into  the  postero-inferior 
quadrant,  immediately  behind  the  tympanic  ring,  and  with  its  concavity 
looking  forward.  In  this  position,  and  keeping  the  hook  close  to  the 
annulus  throughout  the  course,  it  is  carried  around  the  tympanum  either 
until  the  ossicle  is  encountered  and  withdrawn  or  until  a  complete 
circuit  has  demonstrated  that  it  does  not  lie  in  the  path  pursued  by 


FIG.  220. — INCUS  HOOKS,  RIGHT  AND  LEFT. 

the  hook.  If  not  found,  the  reverse  incus  hook  is  tried  and  the  drum 
cavity  is  explored  in  the  reverse  order  to  that  just  described.  This 
last  movement,  in  which  the  concavity  of  the  hook  is  directed  toward 
the  mastoid  antrum,  makes  it  entirely  possible  for  the  operator  to  drive 
the  ossicle  into  the  mouth  of  the  aditus  ad  antrum,  and  thus  to  lose 
it  in  a  most  unfavorable  situation.  The  surgeon  should,  therefore, 
always  have  such  an  accident  in  mind,  and  by  the  exercise  of  care  and 
gentle  manipulation  avoid  its  occurrence. 

It  sometimes  happens  that,  even  when  known  to  be  present,  the 


CHRONIC    PURULENT   OTITIS    MEDIA  361 

incus  is  difficult  to  find.  If  not  removed,  its  presence  must  continue 
to  excite  trouble,  and  the  condition  of  the  patient  will,  therefore,  continue 
unimproved  because  of  the  incomplete  operation.  Time  spent  in 
gently  searching  for  the  little  bone  is,  therefore,  essential  to  the  cure,  and 
thoroughness  in  every  respect  is  due  the  patient  who  has  entrusted  his 
case  to  the  surgical  procedure. 

Owing  to  the  free  blood  supply  to  the  stapes  this  ossicle  is  seldom 
necrosed.  Its  situation  in  the  pelvis'  of  the  oval  window,  however, 
seems  a  favorable  one  for  the  formation  of  connective  tissue,  which, 
during  the  long  inflammatory  process,  is  often  deposited  in  this  locality 
in  sufficient  amount  to  imprison  the  tiny  bone  and  to  render  it  immov- 
able to  such  a  degree  as  greatly  to  impede  the  passage  of  sound-waves 
into  the  labyrinth.  After  the  larger  ossicles  are  removed  and  the 
field  of  operation  thoroughly  dried,  the  condition  of  mobility  of  the 
stapes  should  be  determined  by  means  of  the  probe  used  under  direct 
inspection  and  illumination.  If  the  foot-plate  is  unduly  covered  by 
adventitious  tissue  and  adhesive  bands  are  found  stretching  from  the 
pelvic  walls  to  the  crura  and  head  of  the  ossicle  in  such  a  way  as  to 
render  it  immovable,  the  hearing  power  of  the  patient  may  in  some 
cases  be  considerably  and  in  others  surprisingly  improved  by  severing 
the  bands  that  fix  the  stapes  immovably  in  the  oval  window.  This  is 
accomplished  by  circumcising  the  new  tissues  of  the  foot-plate  with  a 
straight  knife  (Fig.  141),  the  blade  of  which  will  at  the  same  time  sever 
any  adhesive  bands  attached  to  the  head  or  crura.  After  such  incisions 
the  ossicle  may  be  moved  in  different  directions  by  means  of  a  cotton- 
tipped  probe,  in  order  completely  to  break  up  any  partly  severed  ad- 
hesions and  to  secure  the  greatest  freedom  of  motion;  or,  in  some  cases, 
if  it  is  thought  quite  probable  that  the  adhesions  will  speedily  recur, 
the  ossicle  may  be  completely  removed  by  lifting  it  from  the  window  by 
means  of  a  hook  inserted  between  the  crura  or  by  seizing  the  head  with 
forceps  and  making  traction,  while  at  the  same  time  a  rocking  motion 
is  given  to  the  hand. 

Much  experience  in  intratympanic  surgery  is  requisite  to  remove 
the  stapes  without  serious  injury  to  the  labyrinth.  If  the  incisions 
about  the  foot-plate  should  be  made  too  deeply  or  if  the  stapes  is  torn 
from  the  window  by  violence,  the  fluid  of  the  labyrinth  will  escape  and 
a  distressing  dizziness  and  difficult  locomotion  will  result.  Furthermore, 
since  the  tympanic  cavity  in  these  cases  is  the  seat  of  a  chronic  suppura- 
tion, the  subsequent  probability  of  a  labyrinthine  infection  of  traumatic 
origin  should  be  borne  in  mind. 

After  the  removal  of  the  diseased  portions  of  the  ossicular  chain  has 


3^2          THE  PRINCIPLES  AND  PRACTICE  OF  OTOLOGY 

been  satisfactorily  accomplished,  the  tympanic  walls  are  examined 
by  means  of  the  probe,  in  every  accessible  part,  to  determine  if  there 
are  carious  areas;  and,  if  such  are  present,  to  ascertain  their  location 
and  extent.  The  thickened,  granular,  or  polypoid  areas  of  mucous 
membrane  should  be  thoroughly  cureted  away.  To  efficiently  reach 
every  portion  of  the  diseased  mucosa  a  number  of  different  sized  curets, 
with  varying  curves  of  shank,  will  be  needed.  The  author  prefers  the 
small  sharp  ring  curets  with  malleable  shafts  that  may  be  bent  to  the 
exact  angle  required  to  reach  the  diseased  areas  (Figs.  216,  c,  d).  With 


FIG.  221. — ATTIC  CURET. 

these  sharp  and  accurately  fitting  instruments  the  thickened  membrane 
is  quickly  removed  from  every  part.  Any  carious  portions  of  bone 
that  have  previously  been  detected  are  also  honed  smooth  with  the 
stout  sharp  curets.  Curettage  of  the  attic  is  frequently  best  accom- 
plished by  the  employment  of  the  curet  shown  in  Fig.  221  which  is 
operated  from  within  in  an  outward  direction;  or  by  those  shown  in 
Fig.  222,  a,  b,  which  are  operated  antero posteriorly  or  vice  versa. 

It  is  frequently  found  necessary,  in  order  to  carry  out  in  a  thorough 
manner  the  removal  of  all  the  diseased  structures,  to  chip  away  the 


FIG.  222. — ATTIC  CURETS. 

upper  portions  of  the  outer  wall  of  the  attic.  This  is  indicated  because 
this  portion  lies  in  immediate  contact  with  the  neck  of  the  necrosing 
malleus,  over  which  the  products  of  attic  suppuration  have  passed  for 
an  indefinite  time.  This  is  best  accomplished  by  means  of  Hartmann's 
cutting  forceps  (Fig.  223),  with  which  the  outer  attic  wall  can  be  bitten 
away  to  such  an  extent  as  greatly  to  enlarge  the  communication  between 
the  tympanic  cavity  and  the  external  auditory  meatus.  This  step 
will  greatly  facilitate  the  after-treatment  and  drainage  of  the  attic  space. 
While  the  after-treatment  is  in  most  instances  simple,  nevertheless 
success  or  failure  of  the  operation  depends,  in  no  small  measure,  upon 


CHRONIC    PURULENT   OTITIS    MEDIA  363 

the  efficiency  and  persistency  with  which  the  case  is  subsequently  man- 
aged. Immediately  following  the  completion  of  the  operative  work 
the  fund  us  of  the  ear  is  thoroughly  dried  and  a  strip  of  borated  gauze 
is  inserted  to  the  bottom  of  the  canal  in  such  a  way  that  the  most  distal 
part  lies  in  direct  contact  with  the  entire  inner  wall  of  the  middle  ear. 
Coils  of  the  strip  are  then  loosely  packed  over  this  till  the  concha  is 
reached  and  filled.  Since  it  is  usually  not  desirable  to  disturb  the  first 
dressing  under  twenty-four  or  thirty-six  hours  it  is  safest  in  most  cases 
to  cover  the  entire  auricle  with  several  pads  of  gauze,  over  which,  as  a 
completion  of  the  dressing,  a  roller  bandage  is  applied  as  shown  in 
Fig.  255.  Such  a  dressing  not  only  insures  against  further  infection  of 
the  ear  through  meddlesome  interference  on  part  of  the  patient  or 
attendant,  but  also  secures  the  best  possible  drainage  and  the  greatest 
degree  of  comfort  to  the  patient. 


FIG.  223. — HARTMANN'S  BONE  GOUGE  FOR  THE  REMOVAL  OF  THE  OUTER  ATTIC  WALL. 

In  case  the  hypertrophied  tympanic  mucous  membrane  has  been 
removed  from  a  considerable  area  by  the  curet,  a  very  profuse  sero- 
sanguineous  discharge  occurs  for  the  first  few  days.  During  this  time 
the  method  of  making  the  first  dressing  should  be  repeated  at  the  first 
and  possibly  the  second  subsequent  dressing,  since  no  better  provision 
can  be  made  for  catching  the  discharge  and  providing  against  the 
entrance  of  sepsis  from  without  than  the  plan  here  advised.  At  the 
time  the  first  dressing  is  removed  if  the  strip  taken  from  the  meatus  is 
free  from  odor  and  if,  upon  inspection,  the  middle-ear  cavity  is  found 


364  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

free  from  blood-clots  or  retained  secretion,  no  syringing  or  other  medica- 
tion is  indicated,  since  better  results  will  be  obtained  if  only  a  fresh  sterile 
gauze  strip  be  inserted.  Even  after  several  days,  if  the  discharge  has 
greatly  subsided,  the  daily  insertion  of  a  fresh  strip  of  gauze  may  con- 
stitute the  only  necessary  treatment. 

If,  however,  the  purulent  discharge  continues  and  the  foul  odor 
persists,  antiseptic  cleansing  is  indicated.  The  continuance  of  such  a 
discharge  for  any  considerable  length  of  time  after  the  operation  and 
during  subsequent  treatment  would  indicate  that  the  disease  had  not 
all  been  reached  by  the  operation,  and  that  the  continued  suppuration 
comes  from  the  mastoid  antrum  or  cells.  The  disease  in  such  cases 
can  be  satisfactorily  removed  only  by  the  radical  mastoid  operation 
which  is  fully  described  in  Chapter  XXX. 

After  the  performance  of  ossiculectomy  and  curetment,  granulations 
and  small  polypi  are  sometimes  formed  during  the  healing  process. 
These  must  be  destroyed  at  once  by  caustics,  as  already  described  on 
p.  351.  As  the  discharge  lessens  in  the  cases  that  progress  satisfactorily, 
there  springs  out  a  growth  of  epithelium  from  the  dermal  side  of  the 
tympanic  ring,  wrhich  under  the  most  favorable  circumstances  will 
ultimately  cover  the  drum  cavity,  thus  "  dermatizing "  the  mucous 
membrane  and  rendering  a  further  discharge  impossible.  From  the 
standpoint  of  curing  the  discharge,  such  dermatization  is  highly  desir- 
able, but  from  that  of  the  hearing  function  it  is  unfavorable,  since 
usually  there  is  some  loss  of  hearing,  resulting  from  the  completion  of 
the  process  of  dermatization  of  the  mucous  lining  of  the  tympanic 
cavity. 

If  the  curetage  of  the  Eustachian  tube  has  proved  unsuccessful 
in  shutting  off  the  communication  of  the  tympanic  cavity  from  the 
nasopharynx,  some  discharge  arising  from  the  tube  itself  may  continue 
indefinitely  or  may  be  intermittent  and  occur  only  in  cases  of  an  acute 
nasopharyngitis  with  an  accompanying  tubal  catarrh. 

After  the  cessation  of  a  chronic  aural  discharge,  either  spontaneously 
or  as  a  result  of  medicinal  or  surgical  treatment,  there  remains  per- 
manently, in  the  large  majority  of  cases,  an  opening  through  the  drum 
membrane.  In  such  cases  a  recurrence  of  the  discharge  may  be  brought 
on  by  the  entrance  of  water  into  the  ear  either  intentionally  from  syring- 
ing or  accidentally  from  bathing.  Individuals  with  large  perforations 
through  the  drum  membrane  should,  therefore,  be  warned  as  to  the 
possibility  of  a  recurrence  of  the  former  disease  under  these  circumstances, 
in  order  that  care  may  be  exercised  to  prevent  the  entrance  of  water 
into  the  ear. 


CHAPTER  XXIX 
CHRONIC   MASTOIDITIS 

CAUSATION,    PATHOLOGY,    SYMPTOMS,   AND   DIAGNOSIS 

CHRONIC  inflammatory  affections  of  the  mastoid  are  of  more  frequent 
occurrence  than  has  heretofore  been  recognized.  While  the  disease 
is  commonly  referred  to  as  a  mastoiditis  and  thus  leads  to  the  assump- 
tion that  the  inflammatory  and  suppurative  processes  are  limited  to  the 
mastoid  portion  of  the  temporal  bone,  in  reality  the  extent  of  the  affec- 
tion is  often  much  more  widely  reaching,  as  will  be  pointed  out  in  the 
section  on  the  pathology  of  the  disease,  and  may  involve  not  only  the 
osseous  structures  of  the  middle  ear  and  mastoid  process  but  also  those 
of  the  petrous  portion  of  the  temporal  bone,  including,  of  course,  the 
labyrinth. 

Few  divisions  of  medicine  have  received  more  careful  study  from  the 
standpoint  of  their  anatomy,  pathology,  and  technic  of  operative  treat- 
ment than  has  been  bestowed  in  the  recent  past  upon  the  chronic  sup- 
purative diseases  of  the  temporal  bone.  Much  of  the  knowledge  thus 
obtained  is  already  settled  and  accepted  as  a  standard  of  guidance  in 
practise,  whereas  much  is  still  in  the  developmental  state  and  remains 
to  be  further  worked  out,  or  is  yet  to  have  the  correctness  of  its  prin- 
ciples more  satisfactorily  demonstrated. 

Causation. — Excluding  traumatism,  the  cause  of  chronic  mas- 
toiditis is  always  a  preceding  suppurative  process  within  the  middle  ear. 
The  mastoid  antrum,  when  considered  either  anatomically  or  pathologi- 
cally, must  be  regarded  as  a  part  of  the  cavity  of  the  middle  ear,  because 
the  large  channel  of  communication  between  the  two,  which  is  provided 
by  the  aditus  ad  antrum,  renders  it  certain  that  any  disease  which  may 
originate  in  one  will  be  rapidly  carried  to  the  other,  either  by  the  direct 
extension  of  the  causative  inflammation  or  from  the  transportation  by 
gravity  of  the  pathologic  products  from  the  one  to  the  other  space. 
Both  post-mortem  findings  and  clinical  evidence  teach  the  truth  of  this 
statement.  The  mucous  membrane  which  lines  the  Eustachian  tube 
and  middle  ear  is  continued  in  a  modified  form  directly  into  the  mastoid 
antrum  and  cells.  This  membrane  forms  the  normal  barrier  against 
erosion  by  the  invading  pus  and  hence,  so  long  as  it  is  intact  and  free 

365 


366  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

from  ulceration,  the  damage  resulting  from  entrance  of  purulent  material 
into  the  mastoid  antrum  is  not  likely  to  be  great.  When,  however, 
any  portion  of  this  protective  membrane  becomes  necrotic  from  the 
contact  of  violently  septic  pus  or  from  the  retention  of  pus  or  other 
fluid  under  pressure,  the  underlying  bone  is  then  open  to  invasion  and 
its  death  by  necrosis  will  in  due  time  take  place. 

Normally,  the  cells  of  the  mastoid  process  from  antrum  to  tip  are 
in  communication  with  each  other,  and,  therefore,  pus  that  has  once 


Bone  destroyed 
by  cholesteatoma 


FIG.  224. — CHOLESTEATOMA  OF  MASTOID.     CARIES  OF  JUGULAR  FOSSA. 
(Warren  Museum,  Harvard  Medical  School.     J.  Orne  Green   Collection.) 

entered  the  antrum  may  find  its  way  by  gravity  into  all  these  air  spaces, 
where,  because  of  its  dependent  situation,  it  is  most  likely  to  be  retained 
to  establish  that  pathologic  condition  which  is  characteristic  of  chronic 
mastoiditis. 

Pathology. — Caries  and  Necrosis  of  the  Temporal  Bone. — Of  all 
the  cranial  bones  the  temporal  bone  is  the  most  commonly  attacked 
by  osteitis.  Circumscribed  areas  may  be  destroyed  or  sometimes 
destruction  of  the  whole  temporal  bone  occurs.1  Caries  is  common  in 

1 "  Necrosis  means,  in  contradistinction  from  caries,  complete  death  of  the  bone,  which 
is  brought  about  through  a  disturbance  in  the  nutrient  vessels  with  final  abolishment  of 
the  circulation.  A  reactive  inflammation  takes  place  in  the  region  immediately  around 
the  area  of  diseased  bone.  The  bone,  robbed  of  its  nourishment,  dies  within  the  walls  of 
reactive  granulation  tissue  and  for  lack  of  vessels  no  resorption  takes  place,  so  that  the 
dead  bone  lies  in  a  cavity. 

A  third  process  stands  between  caries  and  necrosis,  called  caries  necrotica,  which 
process  is  common  in  the  temporal  bone,  found  principally  in  the  region  of  its  pneumatic 
cells,  where  through  caries  the  continuity  of  the  thin  bony  plates  are  dissolved  and  the 
bone  becomes  filled  with  granulations." — Suppuration  of  the  Labyrinth,  E.  P.  Friedrich. 


CHRONIC   MASTOIDITIS 


367 


the  recessus  epitympanicus,  the  antrum,  and  in  the  malleus  and  incus. 
The  stapes  is  rarely  attacked.  First,  the  mucous  membrane  becomes 
infiltrated  with  pus  and  just  as  soon  as  the  disease  has  reached  a  certain 
intensity  the  mucoperiosteum  is  in  no  condition  to  nourish  the  bone 


Mastoid  tip 


Styloid 
process 


FIG.  225. — CARIES  OF  WHOLE  MASTOID. 
(Warren  Museum,  Harvard  Medical  School.     J.  Orne  Green   Collection.) 

sufficiently.  As  a  result  the  superficial  part  of  the  bone  dies,  appearing 
whitish,  porous,  crusty,  and  chips  off  easily.  Then  the  caries  extends 
deeper  and  deeper  into  the  bone  until  it  breaks  through  the  cortex, 
forming  one  or  more  fistulae  (see  Figs.  223  and  224).  By  carious  sof ten- 


Broken-down 

osseous  structure 

forming  large 

cavity 


Carious  rupture  into 
cranial  cavity 


FIG.  226. — CARIES   OF  TYMPANIC   ROOF.     MASTOID   OPERATION  AND  TREPHINING;  MENINGITIS;  FATAL. 

ing  the  normal  middle-ear  spaces  may  be  greatly  enlarged  or  be  united 
to  other  cavities  by  destruction  of  dividing  septa;  thus,  caries  of  the 
antrum  may  break  through  into  the  middle  cerebral  fossa  (Fig.  226); 
the  posterior  cerebellar  fossa  (Figs.  227  and  229) ;  the  tympanic  cavity 


368 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


(Fig.  228);  the  external  lateral  semicircular  canal  to  the  vestibule;  the 
mastoid  cells,  and  external  auditory  canal.     Pressure  necrosis  may  take 


Rupture 


FIG.  227. — CARIES  OF  SIGMOID  AND  PETROSAL  GROOVES,  ALSO  OF  EXTERNAL  CORTEX.     MENINGITIS. 
(Warren  Museum,  Harvard  Medical  School.     J.  Orne   Green  collection.) 

place  through  insufficient  drainage  of  the  products  of  secretion  (Fig. 
230).  Bone  is  especially  attacked  in  tuberculosis,  scarlet  fever,  and 
measles,  less  often  in  typhoid  fever,  influenza,  and  diphtheria. 


Tegmen  antri 


FIG.  228. — CARIES  OF  TYMPANIC  FLOOR. 
(Warren  Museum,  Harvard  Medical  School.) 


Through  pressure  by  cholesteatomata  (see  Fig.  231)  necrosis  of 
the  bone  takes  place  and  great  cavities  are  sometimes  formed,  even 
extending  far  into  the  cranial  cavity.  Of  the  general  diseases  syphilis 


CHRONIC   MASTOIDITIS 


369 


causes  caries  especially  in  the  gummatous  stage,  next  most  common  is 
tuberculosis  causing  cheesy  destruction  of  the  tuberculous  inflamed 
tissue.  In  syphilis  and  in  tuberculosis  there  may  be  periostitis  of  the 
squama  without  disease  of  the  middle  ear. 


[Caries  of  antrum 
Opening  leads 
to  sinus  groove 


FIG.  229. — CARIES  OF  SIGMOID  GROOVE.     PHLEBITIS  or  LATERAL  SINUS. 
(Warren  Museum,  Harvard  Medical  School.     J.  Orne  Green  Collection.) 

Symptoms. — Many  individuals  who  suffer  from  chronic  mastoiditis 
make  no  complaint  whatever  concerning  the  ailment,  except  it  be  of  the 
aural  discharge.  Of  this  latter  some  speak  trivially,  while  others  because 
of  the  insignificant  amount  deny  the  presence  of  the  discharge.  Except 


Large  cavity  due  to 

caries.     Opening  into 

sigmoid  groove  and 

cerebellar  fossa 


Diploic  mas- 
toid  tip 


FIG.  230. — LARGE  CAVITY  IN  MASTOID  PROCESS  DUE  TO  PRESSURE  NECROSIS. 

at  the  time  of  an  acute  exacerbation  of  the  chronic  trouble,  at  which 
time  inflammatory  swelling  and  retention  of  the  pus  results  in  pain 
either  deeply  in  the  ear  or  over  the  mastoid — should  a  rupture  have 
taken  place  through  the  cortex  and  a  periostitis  and  postaural  swelling 

24 


370  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

be  set  up — the  patient  is  comfortable  and  follows  his  usual  voca- 
tion. There  is,  therefore,  seldom  any  definite  forewarning  of  the 
fact  that  a  slowly  advancing  necrotic  process  is  taking  place  in  the 
deep-seated  parts  of  the  ear,  and  in  the  very  midst  of  structures 


Tip 


FIG.  231. — CASE  OF  PRESSURE  NECROSIS  FROM  CHOLESTEATOMATA. 
(Warren  Museum,  Harvard  Medical  School.     J.  Orne  Green   Collection.) 

the  invasion  of  which  may,  at  any  time,  lead  to  serious  or  even  fatal 
consequences. 

The  character  of  the  aural  discharge,  the  presence  and  appearance 
of  granulations,  polypi  or  fistula,  or,  indeed,  of  all  the  objective  symptoms 
that  are  found  in  the  middle  ear  and  auditory  canal  of  those  who  are 
subjects  of  chronic  suppurative  otitis  media,  are  observed  in  cases  of 
chronic  mastoiditis;  for,  as  previously  stated,  the  one  disease  is  a  sequel 
to  the  other,  and  the  symptoms  of  each  are,  therefore,  in  a  large  measure 
identical  and  often  entirely  inseparable. 

Although,  as  has  already  been  intimated,  mastoiditis  may  have 
been  present  many  years  in  a  given  case,  its  existence  may  not  be  sus- 
pected by  any  one  unless  something  occurs  to  interfere  with  the  previously 
free  drainage  from  the  middle  ear  or  unless  there  is  an  extension  of  the 
disease  to  the  meninges  or  lateral  sinus;  unless  the  facial  nerve,  peri- 
osteum, or  cervical  lymphatics  are  involved;  or,  finally,  unless  there  is 
absorption  of  septic  material  into  the  general  circulation  with  resulting 
systemic  disturbances. 

In  addition,  therefore,  to  the  symptoms  already  narrated  in  con- 
nection with  chronic  suppurative  otitis  media  (see  p.  325),  the  occur- 


CHRONIC   MASTOIDITIS  371 

rence  of  the  following  symptoms  will  be  diagnostic,  not  of  the  fact 
that  mastoiditis  is  present,  for  that  should  have  already  been  known, 
but  of  the  fact  that  something  of  additional  gravity  in  the  prog- 
ress of  the  disease  has  taken  place  which  indicates  a  new  invasion 
of  territory  and  the  possible  approach  of  danger  to  the  life  of  the 
individual. 

1.  Pain. — So  long  as  free  drainage  from  every  infected  cavity  con- 
nected with  the  middle  ear  is  maintained,  pain  is  seldom  present.     Its 
appearance,  therefore,  is  indicative  of  swelling  in  some  portion  of  the 
drainage  tract,  of  other  obstruction  due  to  the  growth  of  polypi,  choles- 
teatoma  or  dried  pus,  and,  finally,  to  an  extension  of  the  mastoid  disease 
to  the  meninges,  to  the  cerebral  or  cerebellar  structure,  or  to  the  perios- 
teum covering  the  external  surface  of  the  mastoid  process.     The  pain 
may  be  sharp  and  intermittent  or  dull  and  continuous.      It  is  always 
limited    to  the  affected  side  of  the  head  unless  general  meningitis  is 
present.     The  patient  locates  the  pain  in  the  depths  of  the  auditory 
meatus  or  in  the  deeper  portions  of  the  mastoid.     If  of  cerebral  origin 
it  may  be  limited  to  a  small  but  definite  area  at  some  point  far  distant 
from  the  ear,  as  at  the  outer  end  of  the  supraorbital  ridge  or  over  the 
parietal  region  above  the  auricular  attachment.     When  it  is  present 
superficially  over  the  mastoid  region  it  is  usually  due  to  an  infection  of 
the  periosteal  covering  of  the  part,  and  hence  sensitive  areas  may  be 
detected  early  if  deep  pressure  be  made  over  the  usual  seats  of  mastoid 
tenderness  (Fig.  151). 

2.  Localized   swelling,   which   takes   place   over   the   postauricular 
region  (Fig.   181)  or  within  the  auditory  canal.      This  is  due   to   a 
periostitis  and  a  collection  of  pus  which   is  the  result   either  of  the 
superficial  inflammation    or    of    a    rupture    of    the    mastoid    abscess 
through  the  bony  cortex.     The  tumefaction  which  sometimes  occurs 
within  the  meatus  is  seen  on  the  posterosuperior  wall  at  its  junction 
with  the  tympanic  ring,  and  if  sufficiently  large  may  obscure  a  view  of 
the  posterosuperior  quadrant  of  the  membrana  tympani.     The  cause, 
appearance,  and  significance  of  such  a  swelling  differs  in  no  way  from 
that  which  occurs  in  acute  mastoiditis,  and  this  has  already  been  de- 
scribed (see  p.  278).     Glandular  infection  of  the  neck  is  occasionally 
a  cause  of  swelling  in  the  cervical  region  and,  as  a  symptom,  is   seen 
most  frequently  in  cases  where  the  aural  discharge  has  been  irritating 
and  has  eroded  the  skin  of  the  external  meatus,  through  which  the  ab- 
sorption of  septic  material  takes  place.     Cervical  adenitis  of  adjacent 
lymphatic  vessels  and  glands  is  also  common  in  tuberculous  individuals, 
particularly  children. 


372  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

3.  Dizziness  and  Profound  Deafness. — In  a  case  that  has  previously 
been  symptomless,  the  sudden  onset  of  marked  or  total  deafness,  together 
with  tinnitus  aurium  and  dizziness,  is  indicative  of  an  invasion  of  the 
labyrinth.     The  dizziness  will  possibly  amount  only  to  an  unsteadiness 
of  gait  that  requires  constant  attention  on  the  part  of  the  individual 
when    on  his  feet,  or  it  may  be  accompanied  by  vomiting  and  be  of 
such  severe  nature  that  the  patient  must  keep  the  recumbent  posture 
(see  Chapter  XLIIL). 

4.  The  pulse  and  temperature  are  sometimes  affected  in  the    more 
severe   complications  of   mastoiditis.     While   dangerous    infection   of 
the  pneumatic  spaces  of  the  temporal  bone  may  have  long  been  present, 
yet  usually  if  the  drainage  is  good  neither  the  pulse  nor  temperature 
are  greatly  affected.     Should,  however,  a  local  or  general  meningitis 
set  in  or  should  a  sinus  infection  occur,  both  pulse  and    temperature 
will  be  elevated,  and  show  disturbances  somewhat  characteristic  of 
the  respective  diseases  (see  Chapters  XXIV.  to  XXXVII.).    Likewise,  in 
cases  of  brain  abscess  resulting  from  the  infected  mastoid,  the  tempera- 
ture and  pulse  are  both  at  first  raised,  but  later  both  may  become 
very   decidedly   subnormal   and   may  remain   so   for  a   considerable 
time. 

5.  Nystagmus  or  strabismus  occurring  in  any  case  of  chronic  aural 
discharge,  either  of  itself  or  accompanied  by  one  or  more  of  the  above 
symptoms,  should  be  regarded  as  a  suspicious  symptom  of  an  intracranial 
extension.     The  occurrence  of  choked  disc  is  also  an  indication  of 
cerebral  or  of  cerebellar  complication. 

6.  Cessation    0}    the  Aural   Discharge. — Sudden    cessation    of    the 
discharge  from  an  ear  that  has  long  been  suppurating  profusely  is  usually 
due  to  the  fact  that  a  rupture  has  taken  place  which  has  allowed  the 
pus  to  enter  the  cranial  cavity;  or  in  case  the  rupture  takes  place  out- 
ward,   the    pus    collects  under  the  periosteum  over  the  mastoid;  or, 
possibly,  as  in  Bezold's  abscess,  it  dissects  its  way  downward  through 
the  deep  tissues  of  the  neck  (see  Figs.  179,  224,  226  and  267).     In  this 
connection  it  must  not  be  forgotten  that  in  any  discharging  ear  the  cessa- 
tion of  the  flow  may  occur  gradually  as  a  consequence  of  the  natural 
healing  of  the  parts  or  from  the  assistance  due  to  local  treatment,  and 
under  such  circumstances  this  occurrence  should  not  be  construed  as  of 
evil  omen.     But  in  a  case  where  the  discharge  has  been  persistent  and 
of  long  duration;  where  it  has  been  foul  smelling,  and  perhaps  accom- 
panied by  the  presence  of  carious  bone  or  polypi  of  the  middle  ear, 
the  sudden  cessation,  particularly  if  coincident  with  or  quickly  followed 
by  the  above  symptoms  of  pain,  fever,  vertigo,  etc.,  would  be  highly 


CHRONIC   MASTOIDITIS  373 

diagnostic  of  the  fact  that  the  pus  had  found  a  new  outlet,  and  that 
the  resulting  condition  of  the  patient  is  more  than  likely  one  of  great 
danger. 

Diagnosis. — To  determine  merely  that  chronic  mastoiditis  is  present 
in  any  given  case  should  not  be  a  difficult  matter;  but  to  ascertain  the 
exact  nature  and  extent  of  the  mastoid  infection,  and  the  presence  or 
absence  of  dangerous  possibilities  that  have  already  developed  or  are 
likely  to  occur  at  any  time,  is  a  far  more  difficult  task  although  one  of 
vastly  greater  importance.  Briefly  stated,  the  one  consideration  most 
essential  to  the  practical  side  of  the  diagnosis  is  the  definite  determination 
of  the  question  as  to  whether  or  not  there  is  present  in  any  given  case  a 
sufficient  amount  of  disease  to  positively  justify  the  performance  of  a 
difficult  operation  for  its  cure,  an  operation  which  will  disqualify  the 
individual  for  business  or  pleasure  for  at  least  a  month,  and  one  upon 
which  some  probability  of  failure  and  some  possibility  of  danger  are 
attendant.  With  this  one  consideration  foremost  in  mind,  the  following 
points  in  the  examination  should  all  be  carefully  weighed  before  the 
diagnosis  is  made  and  before  an  operation  is  finally  determined 
upon. 

1.  The  history  of  the  case;  the  original  cause  of  the  aural  affection; 
whether  or  not  the  patient  has  previously  received  efficient  treatment 
for  the  discharging  ear,  and  whether  or  not  the  discharge  has  been 
constant,  intermittent,  odorless,  or  foul  smelling. 

2.  The    absence   or    presence  of    aural   polypi,  bloody  or   sanious 
discharges,  necrosed   ossicles   or   tympanic  walls,   aural   or   postaural 
fistula. 

3.  The  presence  or  absence  of  pain,  and  of  normal,  subnormal,  or 
elevated  temperature. 

4.  Whether   or  not  there    are   acute  exacerbations  of    the  ear  dis- 
ease in  which  pain,  swelling,  tenderness,  and  fever  are  present;  also 
as  to  the  presence  or  absence  of  vertigo,  tinnitus  aurium,  and  sudden 
deafness. 

5.  The  information  obtained  by  the  most  thorough  examination  of 
the  fundus  of  the  ear,  the  tympanic  attic,  and  as  much  of   the   aditus 
ad  antrum  as  can  be  reached.     In  this  examination  every  accessible 
diseased  area  should  be  inspected  by  sight  if  possible,  and  this  should 
always  be  supplemented  by  the  exploring  probe  which  is  passed  into 
the  attic  and  over  every  portion  of  the  tympanic  walls  in  the  effort  to 
make  certain    concerning  the  presence  or  absence  of    denuded  areas, 
detached  sequestra,  or  collections  of  cholesteatoma. 

Valuable  and  necessary  as  is  the  preceding  history  of  the  case  as 


374  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

an  item  which  enters  into  the  diagnosis,  much  more  valuable  is  that 
exact  information  which  the  surgeon  obtains  during  his  personal 
inspection  of  that  considerable  portion  of  the  seat  of  the  disease 
which  is  subject  to  examination  by  sight  and  the  touch  of  proper 
instruments. 


CHAPTER  XXX 
CHRONIC  MASTOIDITIS    (Continued) 

TREATMENT.     THE   RADICAL    MASTOID   OPERATION 

Preliminary  Remarks. — As  has  been  stated  in  a  previous  chapter 
(see  p.  353)  many  cases  of  chronic  aural  discharge  are  incurable  by 
either  medicinal  means  or  by  operative  procedure  performed  through 
the  external  auditory  meatus.  A  study  of  the  anatomy  of  the  temporal 
bone  by  the  method  of  making  many  sections  through  it  in  such  direction 
as  will  best  show  the  great  extent  of  its  cellular  interior— or,  one  might 


Cerebellar  semicircular  canals 


Internal  auditory 
meatus 


Stylomastoid  foramen 

FIG.  232. — SECTION  NEARLY  PARALLEL  TO  SUPERIOR  PETROSAL  SINUS  GROOVE. 
Shows  the  wide  extent  of  pneumatic  spaces  connected  with  the  middle  ear. 

more  accurately  say,  the  cavernous  arrangement  of  the  labyrinth  of  air 
spaces  of  the  bone,  and  at  the  same  time  show  their  relation  to  each 
other  and  to  the  vital  structures  in  close  proximity  to  them — is  necessary 
to  a  correct  appreciation  of  the  fact  above  stated — namely,  that  many 
suppurative  aural  affections  are  entirely  incurable  except  by  the  most 
radical  operative  measures  (Figs.  232  to  237).  It  is  evident  that, 
should  infection  and  subsequent  suppuration  once  extend  from  the 

375 


376 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


tympanic  cavity  into  a  labyrinth  of  connected  air  spaces,  such  as  that 
shown  in  Fig.  232,  that  the  natural  drainage  through  the  antrum  and 
middle  ear,  which  lie  at  the  top  of  the  system  of  cavities,  would  not 
furnish  a  sufficiently  good  outlet  to  bring  about  a  cure,  and  that 


Cortex 


Stylomastoid 


Thick  cortex  of :  J£**,*  ^ 

mastoid  tip        ^Sl       .  .-f^~ 

Fie.  233. — VERY  THIN  TEGMEN  TYMPANI      NOTE  LARGE,  THICK-WALLED   CELLS   IN  THE  TIP  OF  THE 

MASTOID  PROCESS. 

surgical  assistance  in  such  instances  is  entirely  necessary  to  rid    the 
structures  of  the  disease. 

The  radical  mastoid  operation  may,  therefore,  be  defined  as  a  surgical 
procedure  which  is  intended  for  the  cure  of  that  class  of  chronic  suppura- 


Pneumatic  cells 

external  to  tym- 

panomastoid  duct 


Sigmoid  sinus  groove 
Bi 


Very  thin  cortex 


FIG.  234. — SECTION  OF  TEMPORAL  RONE  ON  A  PLANE  EXTERNAL  TO  THE  MASTOID  ANTRUM  AND  TYMPANIC 

CAVITY. 

The  section  is  made  at  an  angle  that  includes  the  knee  of  the  sigmoid  sinus  groove,  and  hence  shows  the  very 
close  relation  of  the  cells  to  the  sigmoid  sinus. 

ting  ears  in  which  the  seat  of  the  suppurative  process  cannot  be  effec- 
tively reached  by  measures  directed  through  the  external  auditory 
meatus.  The  radical  mastoid  operation  is  essentially  one  that  is  intended 


CHRONIC    MASTOIDITIS 


377 


to  remove  the  suppurative  products,  which  are  the  result  of  necrosis 
of   both  soft  and  osseous  tissues  from  every  accessible  portion  of  the 


Deep  cells  connected 
with  mastoid  antrum 


Tegmen  celluli 


Tympanomastoid 

semicircular  canal 

_  {  Cerebellar  serr.i- 

j  circular  canal 


FIG.  235.— VERTICAL  SECTION  OF  TEMPORAL  BONE  IN  A  PLANE  POSTERIOR  TO  THE  TYMPANIC  CAVITY  AND 

MASTOID  ANTRUM. 

Deep  cells  are  seen  extending  backward  as  far  as  the  sigmoid  sinus,  from  which  they  are  separated  by  a  very 

thin  osseous  lamella. 

temporal  bone.     The  operation,  therefore,  includes  the  diseased  struc- 
tures of  the  middle  ear  as  well  as  those  of  the  mastoid  antrum   and 

Posterior  wall  of 
jugular  fossa 
Cerebellar  semi-  f 
circular  canal  \ 
Large  pneu- 
matic cell 
Aqueductus 
vestibuli 

^ 

Posterior 
condyloid 
foramen 


iploe 


Diploe 


FIG.  236.— SECTION  OF  TEMPORAL  AND  OCCIPITAL  BONES  THROUGH  JUGULAR  FOSSA  SHOWING  LARGE  PNEU- 
MATIC CELLS  SURROUNDING  THIS  FOSSA. 
Note  the  great  depth  of  these  cells  and  their  connection  with  superficial  mastoid  cells. 

cells,  and  from  all  these  cavities  sequestra,  carious  bone,  polypi,  choles- 
teatoma  or,  indeed,  every  pathologic  accumulation  of   whatever   kind 


THE    PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 

that  has  either  invaded  or  resulted  from  the  invasion  of  the    original 
disease  must  be  removed. 

It  will  be  seen  from  the  wide  scope  of  the  radical  operation  that  it 
differs  greatly  from  the  simpler  one  which  is  performed  for  the  cure 
of  acute  mastoid  suppuration.  The  simple  operation  should,  of  course, 
always  be  radically  performed,  in  the  sense  that  it  ought,  in  every  in- 
stance, to  be  carried  out  in  a  thorough  manner;  but  in  cases  where  the 
simple  operation  is  indicated  the  disease  has  been  of  short  duration,  has 
only  involved  but  not  hopelessly  destroyed  the  parts  of  the  middle  ear  that 
are  intended  for  the  conduction  of  sound-waves,  and,  as  stated  in  the 
chapter  descriptive  of  this  operation,  these  essential  parts  of  the  organ 


Digastric 
groove 


FIG.  237. — PERPENDICULAR  SECTION  OF  THE  TEMPORAL  BONE  POSTERIOR  TO  THE  STYLOMASTOID  FORAMEN. 

The  specimen  shows  the  great  extent  of  cellular  development  with  which  the  operator  may  meet.     Note  that 

the  cells  surround  the  sigmoid  sinus  for  a  long  distance. 

of  hearing  can,  by  the  timely  performance  of  the  simple  mastoid  opera- 
tion, usually  be  saved  from  serious  impairment  of  function,  and,  therefore, 
the  subsequent  hearing  of  the  individual  will  be  preserved  to  a  useful 
and  satisfactory  degree.  In  the  performance  of  the  simple  procedure 
the  middle  ear  is  not  entered  nor  are  its  contents  disturbed.  The 
operation  performed  for  the  relief  of  acute  mastoiditis  has,  therefore,  a 
twofold  purpose — namely,  to  evacuate  the  pus  and  necrotic  accumulation 
within  the  mastoid  and  to  preserve  and  restore  the  patient's  hearing. 

The  radical  operation  is  largely  concerned  in  ridding  the  patient  of 
pyogenic  tissues,  and  the  consequent  prevention  of  sequelae  dangerous 
to  life,  which  are  likely  to  arise  from  their  continued  presence  in  the 
temporal  bone.  In  other  words,  it  is  intended  as  a  life-saving  measure 
rather  than  one  in  which  improvement  of  hearing  is  concerned;  for 
usually  by  the  time  the  radical  mastoid  operation  is  indicated  the 


CHRONIC    MASTOIDITIS  37Q 

damage  already  done  within  the  middle  ear — and  not  infrequently 
to  the  labyrinth  also — has  been  sufficient  to  destroy  or  at  least  very 
seriously  to  impair  the  function,  and  hence  the  operation  itself  will 
most  probably  affect  the  remaining  hearing  power  neither  for  better 
nor  worse.  It  has  been  considered  necessary  to  state  the  above  differ- 
ences between  the  simple  and  radical  mastoid  operation  for  the  reason 
that  some  confusion  exists  in  the  minds  of  many  physicians  concerning 
the  nature  and  purpose  of  each  procedure. 

Indications  I  or  the  Performance  of  the  Radical  Mastoid  Operation. — 
i.  Failure  to  cure  a  chronic  aural  discharge  after  following  out  in  a 
painstaking  and  thorough  manner  for  a  period  of  six  weeks  to  three 
months  the  measures  set  forth  in  the  chapter  devoted  to  the  treatment 
of  chronic  suppurative  aural  disease  (see  p.  399). 

2.  The  occurrence  of  pain  over  the  mastoid,  within  the  ear  or  radia- 
ting over  the  side  of  the  head,  particularly  if  this  becomes  persistent 
and  severe  and  can  be  connected  with  the  chronic  otorrhea. 

3.  Continuous  or  frequently  repeated   attacks  of  dizziness  when 
associated  with  chronic  aural  discharge,  the  presence  of  aural  polypi, 
or  with  necrosed  bone  in  the  middle  ear  or  attic. 

4.  The   presence  of   a  postauricular  fistula  or  of  a  fistula  of  the 
posterosuperior  wall  of  the  external  auditory  meatus,  which,  upon  ex- 
amination with  a  probe,  is  found    to   extend   deeply  into  the  mastoid 
interior. 

5.  The  occurrence  of  postauricular  mastoid  tenderness  and  swell- 
ing in  connection  with  chronic  aural  suppuration. 

6.  In  any  case  of  chronic  suppurative  otitis  media  in  which  there 
is  present  a  more  or  less  complete  occlusion  of  the  external  auditory 
meatus,  due  to  diffuse  external  otitis,  osteoma,  or  other  tumor. 

7.  When   symptoms   of   meningitis,   sinus   thrombosis,   or  abscess 
of  the  brain  appear. 

8.  The  presence  of  cholesteatoma  in  the  attic  or  mastoid  antrum. 

9.  The  sudden  cessation  of  a  profuse  aural  discharge  coincident 
with  the  development  of  one  or  more  of  the  above  symptoms. 

The  radical  operation  will  prove  unsuccessful  as  a  curative  measure 
unless  all  the  diseased  tissue  is  by  it  removed;  and,  as  has  already  been 
seen  (Figs.  232  and  234),  the  suppuration  may  include  very  extensive  and 
deepseated  portions  of  the  temporal  bone,  in  which  case  an  operation  to 
be  as  thorough  and  extensive  as  the  condition  demands  is  not  without 
danger  to  life.  It  becomes  a  debatable  question,  therefore,  in  cases 
where  no  severe  pain  is  present,  and  when  no  visible  danger  is  threatening 
the  life  of  the  individual,  whether  it  is  wiser  to  advise  immediate  opera- 


380  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

lion  or  to  permit  the  disease  to  continue  until  some  more  urgent  necessity 
for  surgical  interference  arises.  In  these  comparatively  symptomless 
cases  the  surgeon  should  obtain  every  possible  amount  of  information 
concerning  the  exact  condition  of  the  disease  in  the  middle  ear  and 
mastoid  process,  such  information  being  secured,  of  course,  by  an 
actual  examination  by  every  known  means,  before  he  may  consider  that 
he  is  justified  in  undertaking  to  perform  the  radical  mastoid  operation. 
While,  as  stated  in  indication  number  i  above,  it  is  usually  thought 
advisible  to  treat  a  chronic  discharging  ear  for  a  few  weeks  before 
resorting  to  radical  measures,  yet,  in  practise,  this  preliminary  treatment 
which  is  administered  in  the  hope  of  curing  the  suppuration  and  thus 
averting  the  necessity  for  surgical  interference,  is  often  given  without 
the  slightest  expectation  by  the  surgeon  of  any  permanent  relief,  because 
it  is  clear  from  the  beginning  that  he  is  helpless  to  cure  the  disease  which 
his  first  examination  had  positively  proved  to  lie  entirely  beyond  the 
reach  of  any  trivial  method  of  treatment.  When,  therefore,  the  presence 
of  necrotic  osseous  areas  is  definitely  determined  in  any  case,  and  there 
is  every  probability  that  the  pus  which  is  discharging  from  the  ear  has 
its  origin  in  the  deeper  mastoid  cells  and  antrum,  it  is  no  doubt  the 
wisest  plan  not  to  advise  operative  postponement  because  delay  is 
unsurgical,  and  prompt  determination  in  attacking  the  seat  of  the 
disease  in  a  rational  way  will  not  only  cure  the  suppuration  but  may  also 
prove  the  means  of  saving  the  life  of  the  patient. 

The  fact  that  cases  are  frequently  observed  who  have  passed  from 
childhood  into  old  age  with  a  suppurating  middle  ear  or  mastoid  without 
developing  any  serious  symptoms,  and  with  apparently  no  danger  to 
life,  is  not  altogether  good  argument  against  the  necessity  for  the  radical 
mastoid  operation  in  other  cases  that  are,  apparently,  similarly  diseased, 
because  numerous  cases  have  been  reported  in  which  an  individual  so 
affected  was  able  to  work  at  hard  manual  labor  up  to  the  very  hour 
that  violent  and  fatal  symptoms  first  manifested  themselves.  Further- 
more, during  the  performance  of  the  radical  mastoid  operation  on  per- 
sons who  previously  had  manifested  absolutely  no  dangerous  symptoms, 
it  is  frequently  found  that  the  dura  mater  over  the  tegmen  antri  or 
tympani,  or  over  the  lateral  sinus  in  the  sigmoid  groove,  has  been  laid 
bare  by  the  necrotic  process,  and  that  the  sinus  itself  or  the  exposed 
portion  of  the  dura  mater  is  covered  with  granulations  and  bathed  in 
pus.  Certainly  these  cases  are  in  constant  danger  of  general  infection 
and  should,  therefore,  be  dealt  with  according  to  the  well-established 
principles  of  surgery. 

In  those  who  are  past  sixty  years  of  age  and  in  cases  where   pul- 


CHRONIC    MASTOIDITIS  381 

monary  tuberculosis  or  other  cachectic  disease  accompanies  a  chronic 
aural  discharge,  the  radical  mastoid  operation  is  not  indicated  except 
when  severe  pain  or  other  symptoms  arise  that  urgently  demand  relief. 

Technic  of  the  Radical  Mastoid  Operation. — The  preparation 
of  the  field  of  operation  is  exactly  the  same  as  that  advised  preliminary 
to  the  operation  for  acute  mastoiditis.  In  addition  to  this  if  it  is  probable 
than  an  intracranial  complication  exists  which  would  require  opening 
the  skull  at  some  point,  the  whole  scalp  or  at  least  the  whole  of  the 
affected  side  of  the  head  should  be  shaved,  scrubbed,  and  dressed  with  a 
bichlorid  pack  on  the  evening  previous  to  the  day  of  the  operation. 
Since  it  is  usually  the  intention  to  close  the  postauricular  incisions  im- 
mediately in  the  radical  operation,  and  since  in  some  cases  grafting  of 
the  uncovered  portions  of  the  osseous  wound  can  be  immediately  and 
successfully  performed  after  the  removal  of  all  the  disease,  it  is  highly 
essential  to  have  an  absolutely  sterile  operative  field,  both  inside  the 
old  suppurative  cavity  and  on  the  skin  covering  the  mastoid  region. 
To  secure  this  end  it  is  necessary  in  the  cases  where  no  emergency 
exists  not  only  to  thoroughly  syringe  the  external  auditory  canal  with 
antiseptic  solutions  but  also  to  use  the  attic  syringe  (see  Fig.  208)  for  the 
purpose  of  dislodging  any  masses  of  cholesteatoma  or  dried  secretion  that 
may  be  concealed  in  this  location.  This  should  be  followed  by  filling 
the  external  auditory  meatus  three  times  a  day  for  several  days  pre- 
ceding the  mastoid  operation  with  the  alcohol  and  boric  acid  preparation 
(see  formula,  p.  227). 

Immediately  before  the  commencement  of  the  operation  additional 
antiseptic  precaution  may  be  advantageously  taken  by  applying  a 
solution  of  bichlorid  of  mercury,  i :  1000  in  alcohol,  to  the  walls  and 
hairy  parts  of  the  external  meatus.  This  solution  should  be  vigorously 
rubbed  into  the  skin  by  means  of  cotton  twisted  upon  a  stout  applicator. 
A  wick  of  narrow  gauze  which  has  been  previously  saturated  with  the 
same  solution  is  then  inserted  into  the  canal  to  its  bottom  or  even  into 
the  cavity  of  the  middle  ear  if  the  drum  membrane  is  wanting.  This 
strip  is  removed  as  soon  as  the  primary  incisions  are  completed. 

Whereas  it  is  permissible  to  perform  the  simple  mastoid  operation 
in  the  home  of  the  patient  when  the  surroundings  are  clean  and  the 
operator  can  secure  good  light,  it  is  seldom  advisable  either  in  the 
interest  of  the  patient  or  surgeon  to  undertake  the  radical  procedure 
outside  of  a  well-equipped  hospital,  for  the  reason  that  in  doing  a  com- 
plete operation  it  frequently  becomes  necessary  to  expose  or  open  the 
cranial  cavity  or  lateral  sinus;  or  either  may  be  uncovered  accidentally. 
In  either  instance  the  necessary  after-treatment  can  be  carried  out 


382 


THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


antiseptically  in  the  modern  hospital,  but  is  usually  questionable  and 
therefore  often  dangerous  when  attempted  even  in  the  best  appointed 
household. 

The  primary  incision  is  begun  at  the  tip  of  the  mastoid  process 
exactly  as  in  the  simple  operation,  and  is  likewise  carried  upward 
parallel  to  the  furrow  in  the  skin  which  indicates  the  attachment  of 
the  pinna  and  |  inch  posterior  to  it.  This  curvilinear  cut  is  carried 
upward  over  the  superior  attachment  of  the  auricle  further  than  in  the 
simple  case,  for,  as  will  be  presently  stated,  it  is  necessary,  as  the  opera- 
tion proceeds,  to  detach  the  soft  tissues  of  the  superior  as  well  as  those 


FIG.  238. — THE  LINE  OF  PRIMARY  INCISION  FOR  THE  RADICAL  MASTOID  OPERATION. 
This  line  may  be  extended  forward  or  downward,  if  found  necessary,  at  any  time  during  the  progress  of 
the  operation.     An  additional  backward  incision  may  also  be  made  from  the  center  of  the  first  if  thought  advis- 
able.    See  also  Fig.  276,  line  A  B. 

of  the  posterior  wall  of  the  external  meatus;  and  to  do  this  easily  re- 
quires that  the  skin,  superficial  fascia,  and  sometimes  the  fibers  of  the 
temporal  muscle  and  underlying  periosteum  be  incised  to  the  point 
above  the  ear  shown  in  Fig.  238.  Advantage  is  gained  in  most  cases 
by  making,  in  addition  to  this,  the  horizontal  backward  incision  shown 
in  Fig.  240.  This  can  be  done  either  at  the  time  of  making  the  primary 
curvilinear  cut  or  at  any  subsequent  period  when  it  may  be  decided  that 
a  more  exposed  area  of  the  mastoid  is  for  some  reason  necessary. 

The  anterior  and  posterior  flaps  are  then  detached  from  the  bone 
and  turned  respectively  backward  and  forward  by  means  of  the  sharp 
periosteal  elevator  (see  Fig.  161);  the  anterior  being  reflected  to  a  point 


CHRONIC    MASTOIDITIS 


383 


sufficient  to  expose  clearly  to  view  the  posterior  margin  of  the  mouth  of 
the  auditory  meatus.  The  blunt  periosteal  elevator  (Fig.  239)  is  then 
substituted  for  the  sharp  one.  This  latter  instrument  is  so  constructed 


FIG.  239. — PERIOSTEAL  ELEVATOR  FOR  THE  SEPARATION-  OF  THE  SOFT  TISSUES  OF  THE  EXTERNAL  AUDITORY 

MEATUS  FROM  THE  UNDERLYING  BONE. 
The  shape  of  the  tip  is  adapted  to  that  of  the  osseous  auditory  meatus. 

that  its  shape  and  size  adapts  itself  to  that  of  the  meatal  walls  of  the 
osseous  portion  of  the  auditory  canal,  and  hence  with  it  the  skin  and 
periosteal  lining  of  the  posterior  and  superior  walls  of  the  canal  can  be 
quickly  separated  from  the  bone  down  to  the  tympanic  ring  (Fig.  240). 


FIG.  240. — THE  OSSEOUS  MASTOID  FIELD  DENUDED  PREPARATORY  TO  THE  PERFORMANCE  OF  THE  RADICAL 

MASTOID  OPERATION. 

The  boundaries  of  the  suprameatal  triangle  show  dearly  beneath  the  linea  temporalis.  Note  that  the 
soft  tissues  are  completely  separated  from  the  posterior  and  upper  walls  of  the  bony  meatus.  Compare  Fig. 
163  in  which  the  soft  tissues  are  reflected  for  the  operation  suitable  for  acute  mastoiditis. 

If  the  drum  membrane  was  previously  found  to  be  wanting  the  dissec- 
tion is  continued  to  the  bottom  of  the  auditory  meatus  and  until  the 
inner  end  of  the  separated  portion  of  the  tube  lies  loosely  at  the  seat  of 


384  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

its  former  attachment  to  the  annulus  tympanicus.  In  case  the  tympanic 
membrane  is  partly  present  it  is  advisable  to  incise  the  canal  walls  at  a 
right  angle  to  its  axis  just  exterior  to  the  tympanic  ring,  since  if  one  or 
more  of  the  ossicles  are  present  and  attached  to  the  remnant  of  the  drum 
membrane,  it  would  be  possible  to  wrench  the  stapes  from  its  position 
if  the  above  incision  had  not  already  separated  the  drum  membrane 
and  its  ossicular  attachment  from  the  integumentary  lining  of  the  canal. 
After  the  flaps  are  reflected  the  landmarks  of  the  exposed  mastoid 
are  discernible,  provided  all  the  bleeding  points  have  been  clamped 
and  the  accumulated  blood  has  been  absorbed  by  the  gauze.  The 
chiseling  of  the  bone  is  begun  at  the  same  point  and  the  mastoid  antrum 


FIG.  241. — EBURNATED  MASTOID  PROCESS,  NOT  A  SINGLE  CELL  APPEARING  IN  THE  WHOLE  SECTION. 

is  opened  in  exactly  the  same  manner  as  previously  described  and 
illustrated  (Fig.  168).  If  desired,  however,  the  superoposterior  wall 
of  the  external  meatus  may  be  cut  away  together  with  the  adjoining 
bone  at  the  same  time  that  the  wound  is  deepened  in  the  direction  of 
the  antrum.  In  operating  on  the  acutely  inflamed  mastoid  it  is  quite 
a  common  occurrence  to  uncover  superficial  cells  immediately  after 
the  cortex  is  chiseled  off;  but  such  cells,  lying  so  near  the  surface,  are 
much  more  rarely  met  with  in  the  chronic  case  when  performing  the 
radical  mastoid  operation.  In  this  latter  class  of  cases  where  there 
has  been  a  long-continued  inflammation  in  the  bone,  granulation  tissue 
sometimes  fills  the  mastoid  cells;  this  later  becomes  fibrous,  and  after  a 
long  time  ossification  takes  place  and  many  of  the  cellular  spaces  become 


CHRONIC   MASTOID1TIS 


385 


finally  obliterated  (see  Fig.  241).  When  the  last  stage  of  the  inflamma- 
tory process  is  reached,  osteosclerosis,  or  eburnation  of  the  mastoid,  is 
said  to  have  taken  place  (Fig.  241).  The  mastoid  antrum  itself  and  the 
posterior  meatal  wall  may  be  involved  in  the  osteosclerotic  process,  and 
when  this  is  the  case  the  cavity  of  the  antrum  may  be  greatly  lessened 
in  size  and  the  deeper  portion  of  the  external  auditory  meatus  may,  as 
a  result,  become  very  much  narrowed. 

Should  osteosclerosis  have  taken  place  the  operator  must  expect 
to  chisel  from  cortex  to  antrum  through  the  ivory-like  bone  without 
encountering  any  cellular  structure.  He  must  also  bear  in  mind  the 


FIG.  242. — JANSEN'S  SET  OF  MASTOID  CHISELS.     (See  also  gouges  shown  in  Figs.  167  to  172). 

fact  that  the  mastoid  antrum  will  very  likely  be  much  smaller  than 
normal;  moreover,  because  of  the  encroachment  upon  this  cavity  by 
the  sclerosed  surrounding  bone,  the  antrum  may  be  displaced  slightly 
upward  or  inward  and  forward  toward  the  middle  ear,  and  therefore 
may  be  very  difficult  to  reach.  It  may  be  profitably  stated  here  that 
chisels  made  of  the  finest  steel,  the  edges  of  which  are  in  perfect  order, 
are  necessary  to  penetrate  the  dense  bone,  and  that,  therefore,  in  per- 
forming the  radical  operation  it  is  wise  to  have  an  additional  number  of 
different  sized  chisels  and  gouges  (Figs.  242  and  167  to  172),  so  that  no 
delay  may  result  from  compulsory  chiseling  with  dull  instruments. 

25 


386  THE    PRINCIPLES    AND   PRACTICE   OF   OTOLOGY 

The  precaution  previously  given  as  to  the  proper  method  in  the 
employment  of  the  gouges  should  be  observed  in  this  operation,  and 
it  is  highly  essential  to  the  safety  of  the  patient  that  the  osseous  cavity 
shall,  as  the  work  progresses,  be  kept  entirely  free  from  collections  of 
bony  chips  or  blood,  so  that  the  operator  may  at  all  times  be  able  to 
recognize  the  earliest  approach  to  any  cell,  mastoid  or  otherwise,  and 
to  use  at  once  the  exploring  instrument  in  order  to  determine  the  nature 
and  extent  of  the  space  that  is  uncovered.  Should  these  rules  be  followed 


FIGS.  243,  244,  AND  245. — HAMMOND'S  MASTOID  CURETS. 
Each  is  provided  with  a  sharp,  curved  beak. 

in  all  radical  mastoid  operations  the  danger  areas  which  are  normally 
situated  close  to  portions  of  bone  which  must  be  chiseled  away  may 
usually  be  successfully  avoided,  whereas  otherwise  they  would  be  almost 
certainly  encountered  and  injured. 

As  the  wound  deepens  the  sharp  curet  (Figs.  243  to  247  a  and  247  b) 
should  be  employed  when  possible  in  the  further  removal  of  bone. 
Should  the  bone  be  soft  enough  the  opening  can,  by  the  use  of  this  in- 
strument driven  in  the  direction  of  the  antrum,  be  very  rapidly  deepened, 


CHRONIC    MASTOIDITIS 


387 


and  the  mastoid  antrum  be  thus  uncovered.  The  operator  may  know 
that  he  has  entered  the  antrum  when  the  exploring  probe  (see  Fig.  173) 
can  be  passed  for  a  distance  of  several  millimeters  in  the  direction  of 
the  middle  ear,  and  perhaps  for  a  considerable  distance  under  over- 
hanging ledges  of  bone  in  every  direction.  When  it  becomes  certain 
that  the  cavity  which  has  been  partially  uncovered  is  the  antrum,  the 
opening  is  at  once  sufficiently  enlarged  to  permit  the  thorough  explora- 


FlG.      246. McKERNON'S     CURET,     PROVIDED 

WITH  SHARP  CUTTING  EDGE,  WHILE  THE  HANDLE 
FITS  INTO  THE  PALM  OF  THE  OPERATOR'S  HAND. 


FIG.  247. — a,  SMALL  SHARP  MASTOID  CURET;  b, 
CONVENIENT  CURET  FOR  CLEARING  SMALL  ANGLES  OF 
MASTOID  WOUND. 


tion  of  its  walls  on  every  side.  The  contents  of  the  cavity  may  be  found 
to  consist  of  thickened,  polypoid,  or  necrotic  membrane,  of  inspissated 
pus,  or  of  cholesteatomatous  material.  Its  walls  may  be  found  denuded 
in  places,  so  that  rough  and  carious  bone  is  visible  or  can  be  felt  with 
the  explorer.  In  the  worst  cases  it  is  sometimes  discovered  that  the 
bony  partition  separating  the  antrum  from  the  cranial  cavity  above  is 
wanting  and  that  the  dura  mater  lies  exposed  to  direct  infection ;  or  that 


388 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


the  lateral  sinus  may  have  been  encroached  upon  posteriorly  and  is 
bathed  in  pus;  or,  possibly,  the  osseous  covering  is  eroded  and  the  dura 
is  covered  with  necrotic  granulation  tissue.  In  short,  any  of  the  con- 
ditions which  have  been  detailed  in  the  section  on  the  pathology  of  this 
disease  may  be  exposed  and  determined  at  the  time  of  uncovering  the 
antrum. 

' 


Middle  cerebral 
fossa 


Upper  limit 

for  removal 

of  bone 


Inner  end  of 
protector 
(•'acini  nerve 


-  facial  ridge 
S  Sigmoid  sinus 


Cavity  of 
middle  ear 


'  Carotid  artery 

Internal  jugular 
vein 


Facial  nerve 

FIG.  248. — PERPENDICULAR  SECTION  OF  THE  RIGHT  TEMPORAL  BONE  IN  THE  PLANE  OF  THE  EXTERNAL 
AUDITORY  MEATUS  AND  MIDDLE  EAR,  SHOWING  THE  SURGICAL  RELATION  OF  THE  POSTEROSUPERIOR  WALL 
OF  THE  OSSEOUS  AUDITORY  CANAL  TO  THE  ADITUS  AD  ANTRUM  AND  FACIAL  NERVE. 

A  complete  tympano-mastoid  exenteration  has  been  performed  on  the  specimen,  and  a  Stacke  protector 
has  been  inserted  through  the  osseous  opening  from  without  inward;  the  inner  end  of  the  protector  is  seen 
lying  in  the  aditus  ad  antrum  external  to  the  facial  ridge.  The  illustration  is  intended  to  show  the  extent  to 
•which  the  inner  end  of  the  posterosuperior  wall  of  the  osseous  meatus  may  be  removed  without  risk  of  injury 
to  the  facial  nerve.  The  portion  of  the  osseous  meatus  which  is  commonly  removed  during  the  radical  mastoid 
operation  lies  between  lines  A  and  B,  but  in  any  case  in  which  it  is  found  necessary  to  do  so,  all  the  bone 
between  lines  A  and  C  may  be  safely  removed.  It  should  be  observed,  however,  that  the  inner  termination  of 
lines  B  and  C  are  at  the  same  point,  and  it  should  always  be  borne  in  mind  that  the  width  of  bone  at  the  inner 
termination  of  lines  A  and  B  represents  the  greatest  width  of  bone  that  should  ever  be  removed  at  the  inner 
extremity  of  the  external  auditory  meatus.  The  illustration  accurately  shows  that  any  greater  width  of  osseous 
removal  would  injure  the  facial  nerve  as  it  passes  under  the  inner  extremity  of  points  BC. 

If  the  posterosuperior  margin  of  the  posterior  meatal  wall  has  been 
cut  away  at  the  same  time  the  bone  has  been  removed  in  penetrat- 
ing to  the  antrum,  there  will  now  be  left  a  bridge  of  bone  between  the 
antrum  and  the  middle  ear  which  forms  the  outer  wall  of  the  aditus  ad 
antrum  (Fig.  248),  and  in  order  to  connect  these  two  cavities  and 
convert  them  into  one  it  is  necessary  to  remove  this  intervening  bridge. 


CHRONIC   MASTOIDITIS 


389 


To  accomplish  this  is  one  of  the  most  difficult  and  dangerous  steps  of 
the  whole  operation — not  dangerous  to  life,  perhaps,  but  what  is  almost 
equally  serious,  namely,  danger  to  the  function  of  the  facial  nerve,  with 
subsequent  facial  paralysis.  Every  precaution  in  the  use  of  one's 
anatomic  knowledge  and  skill  in  the  manipulation  of  instruments 
is  therefore  necessary  at  this  part  of  the  procedure,  in  order  that  no 
violence  be  done  to  either  the  facial  nerve  or  the  external  semicircular 
canal.  The  Fallopian  canal,  through  which  the  facial  nerve  passes, 
runs  directly  under  the  bridge  of  bone  to  which  reference  has  just  been 


FIG.  249.— STACKE'S  PROTECTOR. 


FIG.  250. — KERRISON'S  BONE-FORCEPS,  FOR  THE  REMOVAL 
OF  THAT  PORTION  OF  THE  INNER  END  OF  THE  EXTERNAL  OSSE- 
OUS MEATUS  WHICH  OVERLIES  THE  ADITUS  AD  ANTRCM. 

As  will  be  seen  by  reference  to  Fig.  248,  the  facial  canal 
lies  immediately  under  the  bone  at  this  place  and  the  nerve  is 
therefore  exposed  to  great  risk  of  injury  during  this  step  of  the 
radical  mastoid  operation.  The  lower  jaw  of  the  instrument 
here  shown  is  inserted  through  the  aditus,  is  lifted  until  it  hugs 
the  ledge  of  bone,  is  then  closed,  and  the  bone  is  bitten  away 
without  danger  to  the  underlying  nerve. 


made,  but  the  lumen  of  the  aditus  ad  antrum  lies  between  the  nerve 
and  the  bridge.  Therefore,  in  chiseling  this  bridge  away  a  protector 
should  be  placed  under  the  bridge,  in  order  to  cover  the  nerve  and 
insure  against  the  penetration  of  the  deeper  parts  by  the  chisel  (Fig. 
249). 

Instead  of  using  the  chisel  and  protector  in  removing  the  bridge 
of  bone  overlying  the  facial  ridge  as  above  described,  the  Kerrison 
cutting  forceps  (Fig.  250),  which  are  made  in  three  sizes  to  suit  the 
various  sizes  of  the  aditus  ad  antrum  that  may  be  met  with,  either  on 


390  THE    PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 

account  of  diseased  conditions  that  are  present  or  of  the  age  of  the  indi- 
vidual, may  be  employed.  The  beak  of  this  instrument,  which  serves 
as  a  protector,  is  inserted  through  the  opening  of  the  aditus,  when,  by 
compressing  the  handles,  the  cutting  surfaces  of  the  upper  jaw  are  driven 
through  the  bone  which  is  thereby  'bitten  away  without  the  possi- 
bility of  danger  to  the  facial  nerve.  Injury  to  this  nerve,  however, 
may  arise  from  the  rude  or  forcible  introduction  of  either  the  Stacke 
protector  or  the  Kerrison  forceps,  and  therefore  the  operator  must  be 
gentle  in  his  efforts  to  insert  either  through  the  opening  under  the 
bridge.  The  assistant  who  holds  the  Stacke  protector  in  place  after 
its  introduction  and  while  the  operator  is  removing  the  bone  can  also 
injure  the  underlying  nerve  should  he  make  too  much  pressure  upon 
the  handle,  which,  acting  upon  the  facial  ridge  as  a  fulcrum,  may  crush 
or  otherwise  injure  the  nerve. 

It  will  be  observed  that  when  the  removal  of  the  posterior  wall  of 
the  meatus  is  not  accomplished  coincident  with  the  deepening  of  the 
bony  channel  that  is  made  in  entering  the  mastoid  antrum,  that  the 
thin  plate  of  bone  left  standing  between  this  opening  and  the  meatus 
will  be  shaped  like  the  side  of  a  truncated  pyramid,  the  base  of  which 
is  represented  by  the  posterior  margin  of  the  external  meatus.  This 
can  be  best  understood  by  a  reference  to  a  specimen  of  the  temporal 
bone  upon  which  the  operation  has  been  thus  completed  (see  Fig.  248). 
Special  attention  is  called  to  the  shape  of  this  wedge  for  the  reason  that 
its  inner  extremity  forms  the  outer  wall  of  the  aditus  ad  antrum  and 
constitutes  the  bridge  of  bone,  of  which  mention  has  already  been  made, 
that  overlies  the  facial  nerve  and  semicircular  canal.  In  the  removal 
of  the  postmeatal  wall,  therefore,  this  triangular  piece  of  bone  here 
described  may  be  cut  away  as  broadly  as  the  whole  width  of  the  external 
meatus  at  its  external  end,  but  as  the  inner  or  antral  end  is  approached 
the  facial  nerve  will  be  injured  if  a  greater  width  is  removed  than  is 
represented  by  the  actual  width  of  the  outer  wall  of  the  aditus  ad  antrum. 

Immediately  after  the  removal  of  the  outer  wall  of  the  aditus,  as 
just  described,  the  overhanging  ledge  of  the  squamous  portion  of  the 
temporal  bone  (see  Figs.  248  and  263),  which  forms  the  outer  wall  of 
the  attic  chamber  of  the  middle  ear,  should  be  ablated.  The  exploring 
instrument  is  first  passed  into  the  attic,  and  by  this  means  the  depth  and 
height  of  this  portion  of  the  tympanic  cavity  are  determined.  Since  the 
transverse  portion  of  the  facial  nerve  traverses  the  inner  wall  of  the 
attic,  this  nerve  may  be  easily  injured  during  the  removal  of  the  outer 
osseous  wall  of  this  cavity.  Therefore  the  greatest  caution  must  be 
observed,  both  in  the  choice  of  instrument  used  and  the  method  of 


CHRONIC   MASTOIDITIS  39! 

employing  the  same,  in  conducting  .this  essential  part  of  the  operation. 
When  the  small  chisel  or  gouge  is  used  the  Stacke  protector  should  be 
inserted  behind  the  overhanging  attic  wall  and  the  chiseling  should  be 
done  directly  down  upon  it.  The  Kerrison  forceps  are  also  safe  for 
this  purpose,  but  it  is  sometimes  impossible  to  use  them,  owing  to  the 
thickness  of  the  cutting  parts  and  the  consequent  difficulty  of  inserting 
the  same  into  proper  position.  Whatever  method  is  selected  it  is  neces- 
sary to  continue  the  removal  of  bone  until  no  overhanging  ledge  exists, 
and  the  bent  explorer  when  introduced  into  the  attic  may  be  withdrawn 
in  any  direction  without  meeting  any  obstruction. 

Following  this  exposure  of  the  attic  all  oozing  of  blood  should  be 
checked  'by  packing  the  interior  of  the  wound  tightly  for  a  few  seconds. 
When  thus  dried  the  entire  middle  ear  is  visible,  and  therefore  if  any 
of  the  drum  membrane,  or  the  ossicles,  or  their  fragments  still  remain, 
they  can  now  be  easily  removed,  and  this  should  always  be  attended  to 
at  this  stage  of  the  procedure.  In  doing  this  it  is  usually  not  desirable 
to  disturb  the  stapes,  and  hence,  in  order  to  prevent  its  injury,  this  ossicle 
should  be  disarticulated  from  the  incus  before  the  others  are  removed. 

Time  will  be  gained  and  the  subsequent  curetment  of  the  middle 
ear  be  made  both  easier  and  safer  should  the  operator  now  pack  the 
cavity  of  the  middle  ear  tightly  with  gauze  and  return  to  the  antral 
portion  of  the  wound,  which  has  by  this  time  ceased  actively  to  ooze, 
and  can,  therefore,  be  better  inspected  than  at  any  previous  period  of 
the  operation. 

The  amount  of  bone  that  should  be  removed  from  the  mastoid 
process  varies  in  almost  every  case,  and  is  determined  largely  by  the 
extent  of  the  necrotic  process  which  has  taken  place  and  by  the  surgical 
principle  which  requires  that  all  the  diseased  cavities  shall  be  left  free 
from  pockets  or  irregularities  of  surface  that  would  interfere  with  the 
successful  application  of  the  skin  flaps,  of  the  skin  grafts,  or  with  the 
subsequent  process  of  healing  by  granulation.  In  the  sclerotic  mastoid 
(see  Fig.  241),  which  has  already  been  described,  it  is  frequently  not  re- 
quired to  remove  more  bone  than  that  which  must  necessarily  be  cut 
away  to  freely  expose  the  antrum,  aditus,  and  attic  of  the  middle  ear; 
whereas,  should  fistulous  channels  have  previously  extended  from  the 
interior  of  the  mastoid  to  its  surface,  or  should  the  pneumatic  spaces, 
instead  of  undergoing  the  osteosclerotic  process,  have  broken  down  (see 
Figs.  224  and  230),  the  greater  part  or  even  the  whole  of  the  mastoid 
process  may  require  removal.  Sometimes,  as  stated  in  the  section  on 
its  pathology,  the  presence  of  a  cholesteotoma  in  the  antrum  will  cause 
an  extensive  absorption  of  the  surrounding  bone;  in  these  cases  it  will 


3Q2  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

usually  be  necessary  to  remove  the  osseous  structures  beyond  the  line 
of  the  cavity  or  until  healthy  bone  is  encountered  in  every  direction.  A 
wide  experience  in  the  surgical  management  of  these  cases  and  an  ex- 
tended observation  of  the  behavior  of  carious  bone  under  different  de- 
grees of  its  surgical  treatment  is  frequently  necessary  in  determining  just 
how  far  the  disease  has  extended,  and  consequently  just  how  much  of  the 
osseous  structure  needs  to  be  cut  away.  In  general,  however,  it  may 
be  said  that  when  bone  has  been  reached  that  seems  hard  and  firm  under 
the  curet,  and  when  there  is  capillary  oozing  from  every  portion  of  its 
freshly  cut  surface,  it  is  safe  to  presume  that  the  operation  has  been 
carried  far  enough,  and  that  nature  will  repair  the  parts  rapidly  if  the 
after-care  be  conducted  according  to  good  surgical  principles. 

When  satisfied  that  the  diseased  portions  of  the  mastoid  process 
which  lie  below  the  antrum  have  been  dealt  with  thoroughly,  the  opera- 
tor again  returns  to  the  tympanum  and  mastoid  antrum.  The  with- 
drawal of  the  gauze  packing  which  was  placed  there  some  minutes  before 
leaves  these  parts  dry  and  easy  of  inspection.  Every  portion  of  the  walls 
and  bony  edges  of  these  cavities  should  at  this  time  be  inspected  with  the 
explorer,  and  any  overhanging  ledge  or  any  suspicious  looking  area  of 
bone  should  be  removed  wherever  found.  A  proper  sized  curet  is 
selected  and  all  polypi,  granulations,  or  thickened  mucous  membrane 
that  may  be  found  in  either  antrum  or  middle  ear  should  be  scraped 
away.  Most  writers  agree  that  the  tympanic  end  of  the  Eustachian 
tube  should  be  thoroughly  cureted  and  its  mucous  membrane  removed, 
to  the  end  that  the  subsequent  healthy  granulation  within  the  tube  will 
close  it  and  thus  shut  off  the  cavities  of  the  middle  ear  from  further 
infection  through  an  extension  from  the  nasopharynx.  However 
thoroughly  the  mastoid  operation  may  be  performed  in  every  other 
particular,  if  the  Eustachian  tube  is  not  closed  by  some  such  procedure 
as  above  stated,  the  patient  will  be  subsequently  liable  to  attacks  of  aural 
discharge  whenever  he  suffers  from  an  acute  nasopharyngitis;  the  influ- 
ence of  the  tube  in  thus  keeping  the  mastoid  wound  infected  may  cause 
an  indefinite  continuance  of  the  aural  discharge  and  to  some  extent,  at 
least,  defeat  the  purpose  of  the  radical  operation.  A  burr  has  been 
devised  for  the  purpose  of  removing  the  tympanic  portion  of  the  tubal 
membrane  and  of  stimulating  the  adjacent  bone  to  the  production  of 
granulation  tissue;  and  this  instrument  may  be  employed  instead  of  the 
curet  if  so  desired.  During  the  use  of  the  curet  for  the  purpose  above 
stated,  deplorable  injuries  may  be  caused  unless  the  operator  is  gentle 
in  its  use,  and  keeps  the  situation  of  all  important  anatomatic  struc- 
tures constantly  in  mind.  By  rude  and  careless  manipulation  of  the 


CHRONIC    MASTOIDITIS  393 

curet  in  the  tympanum  the  horizontal  portion  of  the  facial  nerve  may  be 
readily  injured,  the  stapes  may  be  scratched  from  the  pelvis  of  the  oval 
window,  or  the  dura  mater  may  be  exposed  over  the  tegmen  tympani. 
Puncture  of  the  jugular  bulb  while  cureting  the  floor  of  the  middle  ear  or 
of  the  carotid  artery  while  cureting  the  Eustachian  tube  are  also  possi- 
bilities that  should  not  be  forgotten.  The  chief  reason  for  a  successful 
result  in  one  radical  mastoid  operation  and  failure  in  another  often  lies 
in  the  fact  that  one  operator  is  not  satisfied  to  close  his  wound  until  every 
little  nook  and  comer  of  the  entire  wound  has  not  only  been  freed  from 
disease  but  is  also  made  smooth  and  regular  in  contour,  whereas  another, 


Bulging  osseous 
wall  of  sigmoid 
sinus 


FIG.  251. — TYMPANOMASTOID  EXENTERATION  COMPLETED. 
Note  that  the  cavity  is  smooth  and  free  from  overhanging  ledges  of  hone. 

either  from  carelessness  or  lack  of  training  in  the  principles  of  bone 
surgery,  ignores  such  minute  detail  and  closes  the  wound  over  a  cavity 
so  badly  prepared  to  receive  the  skin  flaps  or  grafts  that  failure  is  inev- 
itable from  the  first.  Hence,  it  cannot  be  said  that  the  bony  wound  is 
properly  prepared  until  every  pocket  of  infection,  every  overhanging 
ledge  of  bone  or  sharply  angular  ridge,  has  received  such  careful  attention 
that  the  resulting  cavity  is  clean  and  smooth  in  every  direction  (Fig. 

251)- 

The  next  step  of  the  radical  mastoid  operation  is  directed  to  the 
repair  by  plastic  methods  of  as  much  of  the  denuded  bone  as  possible 
to  the  ends  that  deformity  may  not  result  and  that  the  wound  will  heal 


394  THE, PRINCIPLES   AND   PRACTICE    OF   OTOLOGY 

in  the  shortest  length  of  time  and  with  the  least  suffering  and  incon- 
venience to  the  patient. 

For  this  purpose  the  posterior  half  of  the  fibrocartilaginous  canal 
is  utilized,  and  from  it  skin  flaps  are  so  cut  that  when  properly  placed 
in  the  wound  they  will  line  as  much  of  the  osseous  cavity  as  possible  with 
actual  integument.  These  skin  flaps  will,  in  addition,  furnish  areas  from 
which  new  epithelium  will  spring  that  will  ultimately  cover  the  remaining 
denuded  area  and  provide  a  permanent  non-secreting  lining  for  the 
entire  wound. 

Two  principal  methods  of  cutting  the  skin  flaps  are  in  general  use, 
and  whether  the  operator  shall  employ  the  one  or  the  other  depends 
much  upon  whether  the  bony  cavity  which  has  resulted  from  the  opera- 
tion is  large  or  small,  and  also  upon  whether  or  not  the  postauricular 
wound  is  to  be  immediately  sutured  or  is  to  be  left  open  for  subsequent 
inspection  and  treatment.  In  general,  it  may  be  said  that  the  Korner 
flap  (Fig.  252)  is  preferable  when  the  mastoid  cavity  is  small  and  when 
the  postauricular  wound  is  to  be  immediately  closed. 

Method  of  Making  the  Korner  Flap. — An  incision  is  made  through 
the  entire  thickness  of  the  posterosuperior  wall  of  the  fibrocartilaginous 
meatus,  beginning  at  its  deepest  or  tympanic  end  and  continuing  out- 
ward along  the  posterosuperior  portion  as  far  as  the  concha.  A  second 
incision,  exactly  similar  and  parallel  to  the  first,  is  made  along  the  postero- 
inferior  portion  and  from  6  to  8  mm.  distant.  A  tongue-shaped  flap 
is  thus  cut  from  the  canal  which  has  an  attachment  only  at  the  concha 
(see  Fig.  252).  Usually  a  free  hemorrhage  results  from  these  incisions 
and  sometimes  one  or  more  spurting  arterioles  will  need  clamping,  torsion, 
or  possibly  ligation.  In  order  to  insure  accurate  and  permanent  appo- 
sition of  this  flap  to  the  posterior  wall  of  the  mastoid  wound,  where  it 
should  be  ultimately  placed,  it  is  necessary  to  dissect  the  skin  of  the 
cartilaginous  meatus  entirely  away  from  the  cartilage  and  other  soft 
parts,  all  of  which  latter  are  cut  off  close  to  the  base  of  the  remaining 
skin  flap  at  the  concha,  after  which  the  integumentary  portion  which 
remains  is  pliable  and  can  be  pushed  backward  to  the  desired  position 
in  the  osseous  wound  of  the  mastoid.  In  order  to  prevent  kinking  of 
this  flap  during  subsequent  dressings  and  to  assure  its  permanency  of 
position,  a  suture  should  be  passed  through  the  periosteum  of  the  adjoin- 
ing auricular  flap,  then  through  the  posterior  portion  of  the  Korner  flap, 
and  the  latter  is  thus  anchored  in  a  position  which  will  be  most  favorable 
to  its  immediate  adhesion  to  the  bone.  If  it  be  determined  that  a  skin 
graft  shall  be  applied  at  the  primary  operation,  this  should  be  done  as 
the  next  step,  after  which  the  postauricular  flaps  are  completely  closed  by 


CHRONIC    MAST01D1T1S 


395 


FIG.  252. — THE  K.ORNER  FLAP. 
The  incision  through  the  soft  tissues  is  extended  below  the  mastoid  tip  further  than  is  usually  necessary. 


FIG.  253. — THE  RADICAL  MASTOID  OPERATION  COMPLETED. 

Drainage  is  secured  through  the  external  auditory  meatus,  which  is  somewhat  enlarged  by  the  reflection 
of  the  flaps.  In  case  the  dura  has  been  exposed  over  sinus  or  legmen  it  is  not  wise  to  suture  the  entire  wound,  as 
here  shown. 

catgut  sutures  (Fig.  253)  and  a  strip  of  gauze  is  inserted  into  the  newly 
made  cavity  through  the  greatly  enlarged  meatus.  The  soft-tissue  flaps 
are  most  conveniently  sutured  by  means  of  half-curved  needles  which 


396  THE   PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 

are  held  in  the  jaws  of  a  medium-sized  needle-holder  (Fig.  254).  The 
method  of  applying  the  strip  of  gauze  is  of  considerable  importance.  By 
means  of  reflected  light  it  must  first  be  seen  that  the  Korner  flap  is  in 
proper  position.  The  narrow  strip  of  gauze  is  then  seized  at  one  end  by 
the  dressing-forceps  and,  under  continued  illumination,  it  is  carried  to  the 
deepest  portion  of  the  wound.  Over  this, one  fold  after  another  is  packed 
up  to  and  against  the  Korner  flap  in  such  a  way  as  to  slightly  stretch  and 
spread  it  out  to  its  full  extent  and  to  gently  press  it  into  snug  apposition 


FIG.  254. — NEEDLE-HOLDER. 


FIG.  255. — ROLLER  BANDAGE. 

Employed  after  completion  of  the  several  mastoid  and 
other  operations  upon  the  ear. 


to  the  raw  surface  of  the  bone.  Tightly  packing  the  cavity  must  be 
avoided  since  it  is  unnecessary,  causes  pain,  and  may  result  in  the  death 
or  sloughing  of  the  flap.  The  first  dressing  is  completed  by  the  plentiful 
application  of  gauze  over  and  about  the  auricle  and  by  a  roller  bandage 
over  all  (Fig.  255). 

The  Pause  Flaps. — These  flaps  are  best  suited  to  cases  in  which  it 
has  been  found  necessary  during  the  operation  to  remove  a  large  amount 
of  the  osseous  structure  of  the  temporal  bone,  in  consequence  of  which 


CHRONIC   MASTOIDITIS 


397 


a  large  cavity  remains  to  be  healed.  They  should  also  be  chosen  when 
either  by  accident  or  intention  the  sigmoid  sinus  or  dura  mater  has 
been  exposed  or  opened.  The  Panse  flaps  are  formed  from  the  posterior 
wall  of  the  fibrocartilaginous  canal  by  making  one  incision  through  the 
entire  thickness  of  the  soft  parts,  exactly  in  the  center  line  of  this  wall, 
and  from  its  deepest  portion  well  out  into  the  concha.  At  the  conchal 
end  of  the  incision  a  second  cut  is  made  at  right  angles  to  the  first 
and  in  an  upward  direction  for  about  6  mm. ;  this  is  followed  by  a  third 
cut,  beginning  at  the  end  of  the  first,  and  extending  downward  through 
the  concha  for  6  mm.,  the  three  incisions  forming  a  J>  which  bounds 


FIG.  256. — FORMATION  OF  THE  FLAPS  (PANSE  METHOD). 

Note  the  situation  of  the  T-incision.     Note  that  the  cartilage  has  been  removed  from  the  upper  flap.     The 
lower  flap  should  be  treated  likewise  before  it  is  stitched  in  place. 

the  two  quadrangular  flaps  that  are  thus  constructed  from  the  post- 
meatal  soft  structures  (Fig.  256).  The  distance  to  which  these  incis- 
ions should  extend  into  the  concha  depends  upon  the  size  of  the 
osseous  cavity  that  is  to  be  lined.  When  this  is  very  large  the  first 
incision,  or  stem  of  the  J,  should  be  carried  to  within  a  short  distance 
of  the  antihelix,  and  the  other  two  should  follow  the  curvature  of  this 
fold  respectively  upward  and  downward  to  a  slightly  greater  distance 
than  has  been  previously  designated.  After  the  Panse  flaps  have  been 
properly  shaped  by  the  above  described  incisions,  and  after  the  cartil- 
aginous portion  of  each  flap  has  been  removed  by  careful  dissection,  the 


398  THE    PRINCIPLES   AND   PRACTICE    OF   OTOLOGY 

remaining  or  integumentary  portion  of  each  should  have  its  denuded 
surface  placed  into  direct  contact  with  the  osseous  portion  of  the  ad- 
joining mastoid  wound,  and  in  this  position  should  be  anchored  by  one 
or  more  catgut  sutures  to  the  adjacent  periosteum  (Fig.  257).  Success 
in  the  employment  of  the  Panse  method  is,  like  that  of  the  method  of 
Korner,  somewhat  dependent  upon  the  complete  removal  of  the  cartil- 
aginous portion  of  each  flap  on  either  side.  To  dissect  out  the  cartil- 
aginous portion  of  each  flap  requires  a  few  minutes,  but  the  advantages 
derived  from  it  are  so  great  that  this  should  not  be  neglected  in  any 
case.  Even  when  the  Panse  method  of  making  the  flaps  has  been 


Upper  flap 

Remnant  of  poste- 
rior meatal  wall 
Knee  of  sinus 
Lower  flap 


FIG.  257. — METHOD  OF  SUTURING  THE  PANSE  FLAPS. 

employed  the  author  has,  in  the  great  majority  of  his  cases,  been  able 
successfully  to  close  the  postauricular  wound  at  once  (see  Fig.  253) 
and  to  secure  a  union  of  all  the  flaps  by  first  intention.  When  a  con- 
siderable part  of  the  concha  has  been  utilized  in  the  formation  of  these 
flaps  the  external  auditory  meatus  is,  of  course,  subsequently  much 
larger  than  normal,  but  this  slight  deformity,  if  such  it  might  be  called, 
is  preferable  to  the  long-continued  treatment  by  the  postauricular  open 
method,  which  will  also  be  likely  to  result  in  a  scar  that  is  more  notice- 
able than  the  enlarged  meatus.  The  provision  of  a  large  meatus  serves 
the  excellent  advantage  of  enabling  the  surgeon  to  at  all  times  see  every 
part  of  the  mastoid  wound  through  this  channel  and  to  thus  be  able  to 


CHRONIC   MASTOIDITIS  399 

carry  on  the  after-treatment  in  an  intelligent  and  most  satisfactory 
manner.  In  all  cases  of  large  mastoid  wound  where  the  Panse  flaps 
have  been  employed,  and  enough  of  the  concha  has  been  included  to 
leave  a  large  meatus,  the  results  have  been  so  good  in  the  author's 
cases  that  he  has  never  regretted  the  immediate  closure  of  the  post- 
auricular  wound.  When  skin-grafts  are  to  be  used  primarily  the  same 
should  be  applied  immediately  after  the  flaps  have  been  properly 
placed  and  the  external  wound  has  been  sutured.  The  insertion  of  the 
gauze  packing  and  the  final  external  dressing  differs  in  no  essential 
respect  from  that  described  as  proper  after  the  Korner  flaps  have  been 
employed. 

Skin  Grafting. — The  length  of  time  necessary  for  the  complete 
healing  of  the  cavity  of  the  mastoid  wound  after  the  radical  mastoid 
operation  may  be  greatly  shortened  by  the  application  of  skin  grafts 
to  all  those  portions  of  the  osseous  wound  which  it  has  been  impossible 
to  cover  by  means  of  the  skin  flaps  heretofore  described.  These  grafts 
may  be  applied  either  at  the  time  of  the  mastoid  operation  or  a  week 
or  ten  days  subsequently,  and  after  the  surface  of  the  cavity  has  begun 
to  granulate.  If  at  the  primary  operation  it  is  possible  to  eradicate  all 
the  foci  of  suppuration,  to  sterilize  the  resulting  cavity,  and  to  leave  a 
smooth  osseous  surface  in  all  parts  of  the  wound,  the  probability  of 
success  resulting  from  the  application  of  the  graft  at  this  time  is  sufficient 
to  warrant  its  trial,  for  should  it  fail  to  take,  no  harm  has  been  done  by 
the  attempt;  and  should  it  succeed  it  will  save  much  time  in  the  healing 
and  will  obviate  the  unpleasant  necessity  for  a  second  general  anesthetic, 
which  must  be  given  should  the  grafts  be  applied  on  some  subsequent 
occasion. 

Should  it  have  been  impossible  at  the  time  of  operation  to  remove  all 
infectious  areas  from  the  mastoid,  and  therefore  a  cavity  be  left  which 
cannot  be  completely  sterilized,  it  would  be  wiser  under  such  circum- 
stances to  wait  a  week  or  ten  days  before  applying  the  grafts,  and  in 
the  interval  to  make  the  necessary  efforts  to  secure  a  cleaner  field  for 
their  reception.  Some  operators,  however,  prefer  to  do  the  grafting  as 
a  secondary  measure  under  all  circumstances. 

Technic  o]  the  Skin  Grafting. — On  the  evening  preceding  the  day 
of  the  mastoid  operation,  and  at  the  same  time  that  the  head  is  surgically 
prepared,  the  area  from  which  the  skin  graft  is  to  be  taken,  the  front 
or  inside  surface  of  the  patient's  thigh,  should  likewise  be  sterilized. 
An  area  6  inches  square  on  one  or  the  other  of  these  regions  should 
therefore  be  shaved,  scrubbed,  and  finally  prepared  by  the  application 
of  a  bichlorid  dressing  (i :  1000),  which  latter  is  bound  over  the  sterilized 


400  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

field  and  allowed  to  remain  until  the  mastoid  wound  is  ready  to  receive 
the  grafts.  At  the  time  this  dressing  is  removed  from  the  thigh 
the  skin  is  rubbed  with  alcohol,  which  is  in  turn  bathed  off  with 
warm  normal  salt  solution.  The  knife  which  is  to  be  used  for  cutting 
the  graft  is  first  dipped  in  warm  saline  solution,  and  while  the  skin 
of  the  prepared  area  on  the  patient's  thigh  is  rendered  tense  by  the 
operator's  left  hand,  its  edge  is  made  to  penetrate  the  layers  of 
epidermis,  after  which  the  blade  is  turned  flat  against  the  skin,  when 
by  means  of  a  rapid  sawing  motion  an  epidermal  graft  2  inches 
square  may  be  quickly  removed.  This  was  formerly  transferred  to  a 
spatula  made  for  the  purpose  and  of  convenient  size  to  enter  the  mastoid 
wound;  and  when  in  proper  position  in  the  deep  portion  of  the  latter 
the  graft  with  the  freshly  cut  surface  presenting  toward  the  bone  was 
slid  from  the  spatula  by  means  of  a  sharp  needle,  and  was  then  spread 
over  the  cavities  of  the  middle  ear  and  antrum  and,  indeed, all  remaining 
uncovered  surfaces.  This  manipulation  of  the  graft  should,  of  course, 
be  done  under  the  guidance  of  reflected  light,  and  should  any  blood  or 
air  collect  under  the  same  it  should  be  sucked  away  by  means  of  a  small 
pipet  upon  the  outer  end  of  which  is  a  suction  bulb.  Upon  the  graft  are 
gently  packed  pledgets  of  sterilized  cotton  or  small  gauze  sponges  until 
the  meatus  is  completely  but  loosely  filled. 

A  more  recent  and  easier  method  of  application,  also  an  equally 
successful  one,  is  to  use  instead  of  the  spatula  a  2  X  2  inch  piece  of 
sterilized  crape  lisse,  upon  which  the  graft  is  evenly  spread  with  its  cut 
surface  outward.  The  crape  is  then  gathered  from  all  its  edges  into  a 
somewhat  cylindric  shape,  and  with  the  graft  still  upon  its  outer 
surface,  it  is  inserted  into  the  depths  of  the  wound  via  the  auditory 
canal,  after  which,  by  means  of  a  probe,  it  is  spread  over  all  the  denuded 
surfaces.  It  seems  not  to  be  absolutely  necessary  to  the  successful 
taking  of  the  graft  that  every  portion  of  it  shall  come  into  direct  contact 
with  the  denuded  bone,  for  wherever  any  area  of  the  graft  touches  the 
bone,  adhesion  takes  place  and  in  this  way  many  islands  of  epidermal 
covering  are  formed,  which  soon  run  together  and  cover  the  whole 
surface  of  the  wound.  Those  portions  of  the  graft  which  are  not  brought 
into  immediate  contact  with  the  wound  will  quickly  die  and  are  brought 
away  on  the  crape  when  it  is  withdrawn  at  the  first  dressing. 

Following  either  method  the  graft  is  left  undisturbed  for  about 
five  days  unless  symptoms  should  arise  which  indicate  an  earlier  change 
of  the  dressing.  When  undisturbed  for  the  full  time  an  odor,  usually 
very  foul,  will  be  present.  This  is  due  to  the  decay  of  those  portions 
of  the  graft  which  were  not  in  contact  with  the  wound  and  which  con- 


CHRONIC    MASTOIDITIS  4OI 

sequently  could  not  adhere  and  grow.  The  odor  is  not,  therefore,  neces- 
sarily indicative  of  failure  of  the  taking  of  the  graft. 

At  the  first  dressing  the  ear  may  be  gently  syringed  with  an  antiseptic 
fluid,  after  which  the  cavity  is  dried  and  a  gauze  wick  packing  is  loosely 
inserted  into  every  part.  This  treatment  must  be  subsequently  repeated 
each  day  in  order  to  keep  the  cavity  sufficiently  dry  to  favor  that  com- 
plete epidermization  which  is  so  necessary  to  the  permanent  cure  of  the 
mastoid  disease.  At  the  first  dressing  subsequent  to  the  mastoid 
operation,  provided  all  has  progressed  normally  and  the  dressing  has 
been  undisturbed  for  five  or  six  days,  it  is  usually  found  that  the  primary 
mastoid  incisions  through  the  soft  tissues  have  united  by  first  intention. 
If  any  suture  has  become  infected  the  same  should  be  removed  and  the 
pustulating  track  of  the  stitch  be  at  once  disinfected,  dried,  and  powdered 
with  boric  acid.  It  is  advisable  to  continue  the  use  of  the  roller  bandage 
for  at  least  a  week  subsequent  to  the  first  dressing,  even  though  the  wound 
at  that  time  seems  well  united,  because  by  its  longer  application  pro- 
vision is  made  not  only  against  infection  from  without  but  also  against 
injury  to  the  tender  mastoid  and  auricle,  which  might  result  from  un- 
conscious movement  of  the  patient  during  sleep. 

At  each  subsequent  treatment  the  wound  is  syringed,  if  thought 
advisable,  with  antiseptic  fluids.  Some  cases  seem  to  do  better  if  the 
cavity  is  only  mopped  dry  and  is  afterward  lightly  powdered  with  some 
antiseptic.  Whatever  the  mode  of  treatment,  the  interior  of  the  wound 
must  each  day  be  inspected  by  means  of  reflected  light  in  order  that  the 
surgeon  may  at  all  times  know  that  the  progress  of  the  healing  is  as  it 
should  be.  If  the  skin  grafts  have  failed  or  have  only  taken  over 
insular  areas,  exuberant  granulations  may  spring  up,  septic  material  be 
retained,  and  additional  death  of  bone  occur.  Any  such  tendency 
should,  of  course,  be  detected  at  once  during  the  after-management. 
Painstaking  care  of  the  wound  during  the  healing  process  is  always 
sufficiently  well  rewarded  by  good  results  to  amply  justify  its  bestowal 
upon  every  case. 

Accidents  and  Dangers  that  may  Occur  during  the  Performance 
of  or  Subsequent  to  the  Radical  Mastoid  Operation. — A  study  of 
the  anatomic  relations  of  the  mastoid  process,  mastoid  antrum,  and 
middle  ear  to  the  cerebrum,  cerebellum,  sigmoid  sinus,  facial  nerve,  and 
semicircular  canals  must  always  lead  the  observer  to  the  conclusion 
that  accident  and  danger  may  lie  in  the  path  of  the  radical  mastoid 
operation  during  nearly  every  step  of  its  performance.  This  conclusion 
becomes  the  more  confirmed  by  a  large  experience  in  operating,  and 
from  an  examination  of  a  great  number  of  temporal  bones,  in  both  of 

26 


402  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

which  ways  it  is  learned  that  frequent  anomalies  of  all  the  structures 
involved  occur,  and  that  the  operator  can  therefore  never  determine 
beforehand,  with  a  helpful  degree  of  certainty  in  any  case,  whether  the 
dangerous  structures  are  normally  placed  beneath  the  cortex  or  whether 
they  traverse  the  very  paths  that  are  usually  followed  through  the  bone 
by  the  operator  in  reaching  the  diseased  tissues  which  he  desires  to 
remove.  As  examples  of  what  is  meant,  it  may  be  cited  that  it  is  not 
uncommon  to  find  the  sigmoid  sinus  running  directly  through  the  field 
covered  by  the  suprameatal  triangle — the  normal  safety  route  for  opening 
into  the  mastoid  antrum  (see  Fig.  183).  Or  the  middle  cerebral  fossa 
may  lie  so  low  that  it  overhangs  the  mastoid  antrum  and  thus  occupies  a 
plane  below  the  linea  temporalis,  the  landmark  that  is  given  as  a  safe  line 
below  which  the  operator  may  chisel  without  endangering  the  brain  at 
this  point.  Fortunately,  the  course  of  the  facial  nerve  seldom,  perhaps 
never,  varies  from  the  normal,  but  its  close  proximity  to  the  most  frequent 
seats  of  the  carious  processes  renders  it  necessary  in  almost  every 
radical  mastoid  operation  to  remove  diseased  bone  in  the  immediate 
vicinity  of  the  Fallopian  canal,  perhaps  often  within  J  mm.  of  it,  and  thus 
the  function  of  the  nerve  is  constantly  endangered  even  in  cases  of 
average  severity.  Furthermore,  the  necrosis  of  the  temporal  bone  may 
extend  to  the  petrous  portion  and  include  the  semicircular  canals  or 
cochlea,  the  removal  of  which  from  these  locations  would  require  the 
most  exact  anatomic  knowledge  and  operative  experience,  as  well  as 
the  most  delicate  touch  in  the  handling  of  instruments;  otherwise  the 
operator  may  wound  these  deep-seated  structures. 

The  first  and  most  essential  requirement  in  the  avoidance  of  these 
accidents  is  that  before  an  operator  undertakes  a  surgical  procedure 
involving  so  many  accidental  and  dangerous  possibilities,  he  should 
have  acquired  the  most  perfect  knowledge  of  the  anatomy  of  the  temporal 
bone  by  having  personally  made  many  sections  and  dissections  of  its 
structure.  In  addition,  he  should  have  performed  the  radical  operation 
on  the  cadaver  many  times  and  should  also  have  witnessed  its  perform- 
ance a  number  of  times  on  actual  patients  by  an  operator  of  great  ex- 
perience. 

The  next  essential  in  the  avoidance  of  danger  is  that  the  primary 
incisions  through  the  soft  tissues  should  always  be  sufficiently  extensive 
to  permit  an  amount  of  exposure  of  the  skull  over  the  mastoid  region  that 
at  the  beginning,  as  well  as  throughout  the  entire  procedure,  will  render 
it  easy  for  the  operator  to  be  certain  of  his  landmarks,  and  to  enable 
him  to  recognize  them  with  certainty  at  any  period  of  the  operation 
(see  Fig.  240). 


CHRONIC   MASTOIDITIS  403 

The  third  essential  is  that  bleeding  from  all  the  larger  vessels  must  be 
controlled  by  clamping,  ligature,  or  torsion,  and  the  capillary  oozing 
by  pressure  when  necessary,  in  order  that  the  wound  may  be  sufficiently 
clear  to  enable  the  operator  to  recognize  the  landmarks  and  the  nature 
of  the  structure  upon  which  he  is  operating.  The  bony  chips  and 
necrotic  debris  must  be  kept  out  of  the  wound  as  rapidly  as  dislodged  by 
the  chisel,  for  skill  in  operating  and  anatomic  knowledge  of  the  struc- 
tures will  be  of  little  service  in  dealing  with  parts  that  are  filled  with 
blood  or  obstructed  by  the  products  of  the  operation.  And,  finally,  a 
good  light  during  all  stages  of  the  operation,  either  natural  or  artificial 
must  at  all  times  be  available. 

Always  begin  the  chiseling  far  forward  in  the  suprameatal  margin. 
This  will  usually  avoid  direct  entrance  into  an  abnormally  placed  sigmoid 
sinus.  By  removing  the  osseous  chips  immediately  after  their  detach- 
ment, by  directing  the  edge  of  the  gouge  toward  the  meatus,  and  by 
observing  constantly  the  surface  from  which  each  chip  is  removed  it  will 
be  possible,  in  all  cases,  to  approach  either  the  sinus  or  dura  and  even 
lay  them  bare  without  risk  of  injury  to  the  dural  structure.  In  this 
connection  it  should  again  be  pointed  out  that  the  frequent  use  of  the 
exploring  probe  will  often  avoid  error. 

In  addition  to  the  above  precautions,  injury  to  the  facial  nerve  may 
usually  be  avoided  by  exercising  the  greatest  care  possible  in  the  removal 
of  the  posterior  portion  of  the  osseous  meatal  wall.  It  is  at  the  deepest 
portion  of  this  wall  that  the  danger  to  the  nerve  is  greatest,  and  hence 
in  cutting  away  the  inner  third  of  its  length  the  operator  should  be 
goverened  by  the  rules  previously  given  for  this  step  of  the  operation. 
The  point  here  to  be  emphasized  is  that  unless  it  can  be  actually  demon- 
strated that  the  ridge  of  the  Fallopian  canal  lies  more  deeply,  the  greatest 
width  to  which  the  postmeatal  wall  can  be  removed  at  its  inner  extremity 
is  represented  by  the  diameter  of  the  aditus  ad  antrum  (see  Fig.  248). 

The  dangers  arising  to  the  facial  nerve,  oval  window,  and  large 
vessels  which  lie  in  close  proximity  to  the  middle  ear  from  a  too  vigorous 
curetment  have  already  been  pointed  out,  and  it  is  now  only  necessary 
to  again  call  attention  to  the  possibilities  of  grave  error  from  this  cause 
and  to  suggest  a  caution  in  the  performance  of  this  necessary,  though 
delicate  part,  of  the  operative  procedure. 

Facial  paralysis  (Figs.  258  and  259)  may  follow  the  radical  mastoid 
operation  as  a  result  of  the  penetration  of  the  Fallopian  canal  by  the 
chisel  or  curet  and  of  the  consequent  injury  or  severance  of  the  facial 
nerve;  or  it  may  be  the  result  of  a  serous  effusion  into  the  Fallopian 
canal  in  sufficient  amount  to  compress  the  nerve  and  in  this  way  to 


404 


THE   PRINCIPLES    AND   PRACTICE    OF   OTOLOGY 


abate  its  function.     In  case  the  latter  is  the  cause,  the  paralysis  of  the 
muscles  supplied  by  the  nerve  will  usually  be  gradual  in  its  development, 

and  the  loss  of  facial  movement 
may  not  be  noticed  for  from  one 
to  several  days  following  the 
mastoid  exenteration.  Should 
the  nerve  trunk  be  severely  con- 
tused or  entirely  severed  during 
the  operation  the  facial  paralysis 
will  be  complete  at  once,  al- 
though it  will  probably  not  be 
detected  until  the  patient  begins 
to  arouse  from  the  anesthetic. 

The  prognosis  as  to  the  res- 
toration of  function  in  postopera- 
tive facial  paralysis  depends  upon 
the  nature  and  severity  of  the 


FIG.  258. — FACIAL  PARALYSIS  RESULTING  FROM  EPI- 

THELIOMA. 

(See  Fig.  69.)    Shows  appearance  of  face  when  patient 
attempts  to  wrinkle  the  forehead. 


cause.     If  the  injury  to  the  nerve 
is   trivial   or  if  there  is  only  a 


traumatic  neuritis  with  effusion 
into  the  sheath  of  the  nerve,  a 
partial  or  complete  restoration 

of   function    may    be    expected    in   from    six  months  to  a  year.     If, 
however,  the  nerve  has  been  greatly  contused  or   completely   severed 


FIG.  259. — VARYING  FACIAL  EXPRESSION  AFTER  DISEASE  OR  INJURY  TO  THE  FACIAL  NERVE. 


CHRONIC    MASTOIDITIS  405 

or  if  a  portion  of  its  trunk  has  been  entirely  destroyed,  the  prognosis 
is  not  favorable  since  the  function  will  not  likely  be  restored,  and  the 
muscles  supplied  by  the  facial  nerve  will  in  time  undergo  more  or  less 
atrophy.  The  peripheral  portion  of  the  nerve  itself  will  finally  atrophy 
until  its  trunk  will  be  difficult  or  impossible  to  find  when  dissections  are 
made  for  that  purpose.  Many  operators  whose  observation  is  worthy 
of  quotation  have  reported  cases  of  recovery  of  function  after  severe 
injury  or  even  after  the  division  or  destruction  of  a  portion  of  the  facial 
nerve.  Bezold  (Z.  /.  O.,  Vol.  XVI.)  reports  the  complete  restoration  of 
the  nerve,  and  consequent  return  of  function  to  the  facial  muscles, 
after  destruction  of  the  greater  portion  of  the  Fallopian  canal  including 
the  facial  nerve.  Pierce  (Trans.  Am.  Laryngol.  Otol.  and  Rhinol.  Soc., 
1906)  states  that  in  a  case  in  which  |  inch  of  the  facial  nerve  was  de- 
stroyed restoration  of  function  occurred  after  a  period  of  nine  years. 

The  treatment  of  the  resulting  facial  palsy  is  medicinal,  mechanical, 
and  surgical.  In  cases  where  it  is  definitely  known  or  strongly  believed 
that  the  nerve  has  been  but  slightly  injured  or  that  there  is  no  injury 
at  all,  but  only  an  effusion  into  the  nerve  sheath,  surgical  treatment  is 
not  indicated  and  the  internal  administration  of  drugs,  together  with 
well  directed  massage  of  the  facial  muscles,  should  be  advocated.  The 
bowels  should  be  kept  freely  open  by  the  administration  of  salines  to 
favor  the  absorption  of  exudates  from  the  sheath  of  the  nerve,  and  later 
strychnin  in  ^V§r-  doses,  three  times  a  day,  may  be  given  to  stimulate 
the  nervous  system.  Massage  of  the  affected  muscles  is  essential  to 
prevent  their  atrophy  and  this  should  be  given  once  or  twice  a  day  for 
a  period  of  at  least  five  minutes,  the  manipulations  including  the  deep- 
seated  as  well  as  the  more  superficial  muscles.  The  application  of  the 
interrupted  electric  current  twice  or  three  times  a  week  will  also  be  of 
service  in  preserving  and  restoring  the  deficient  muscle-tone. 

When  the  facial  paralysis  occurs  immediately  after  the  mastoid 
operation  and  the  operator  knows  that  the  nerve  was  extensively  injured 
during  the  procedure,  surgical  measures  may  be  instituted  at  once  with 
a  view  to  the  restoration  of  the  lost  muscular  function. 

The  Surgery  of  the  Facial  Nerve. — It  has  been  demonstrated  by 
experiment  that  regeneration  will  occur  in  the  peripheral  portion  of  a 
nerve  that  has  partly  degenerated  as  the  result  of  an  injury  to  its  trunk, 
and  that  its  former  function  can  again  be  exercised  if  this  segment  of 
the  nerve  be  grafted  upon  the  central  segment  of  a  healthy  nerve.  Prac- 
tical use  has  been  made  of  this  fact,  and  the  injured  seventh  nerve  has 
been  many  times  united  with  the  spinal  accessory  or  with  the  hypoglossal 
nerve,  and  with  a  fair  degree  of  success  provided  the  operation  is  per- 


406  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

formed  sufficiently  early,  and  before  wasting  of  both  the  nerve-fibers 
and  the  muscles  supplied  by  them  is  too  far  advanced.  Experience 
seems  to  show  that  it  is  better  to  unite  the  facial  with  the  hypoglossal 
than  with  the  spinal  accessory,  for  when  the  latter  has  been  united  with 
the  facial  there  has  followed  an  associated  movement  between  the 
groups  of  muscles  that  produce  shoulder  movement  and  those  which 
produce  face  movement,  which  was  very  annoying  to  the  patient  and 
noticeable  to  the  observer.  In  other  words,  after  the  operation  of 
splicing  the  facial  and  spinal  accessory  nerves  has  been  performed, 
whenever  the  patient  either  voluntarily  or  involuntarily  moves  the  face, 
the  shoulder  of  the  corresponding  side  is  also  moved,  and  vice  versa. 
After  uniting  the  facial  and  hypoglossal  nerves,  persistence  of  the  former 
function  of  the  hypoglossal  nerve  also  gives  rise  to  associated  movements 
of  the  tongue,  but  since  this  movement  takes  place  within  the  mouth, 
and  is  therefore  hidden  from  the  public,  it  is  not  nearly  so  annoying  to 
the  patient. 

The  hypoglossal  nerve  is  exposed  in  the  neck  by  making  an  incision 
along  the  anterior  margin  of  the  sternocleidomastoid  muscle,  extending 
downward  from  a  point  opposite  the  anterior  border  of  the  mastoid 
process  to  a  point  opposite  the  cricoid  cartilage.  The  parotid  gland  is 
exposed  and  held  forward  while  the  sternocleidomastoid  muscle  is 
pulled  backward.  The  deep  fascia  is  opened  throughout  the  whole 
extent  of  the  wound,  exposing  the  trunks  of  both  the  hypoglossal  and 
facial  nerves.  Each  should  be  freed  from  its  connections  to  adjacent 
structures  for  a  sufficient  distance  to  provide  a  combined  length  of  the 
nerves  which  will  enable  the  operator  to  bring  the  two  ends  together 
after  their  trunks  have  been  completely  severed.  The  facial  nerve 
should  be  cut  off  squarely  near  the  point  of  its  exit  from  the  skull  and 
the  hypoglossal  should  be  divided  at  a  point  just  beyond  \vhere  it  crosses 
the  external  carotid  artery.  The  peripheral  portion  of  the  facial  is 
turned  downward  and  the  proximal  end  of  the  hypoglossal  is  turned 
upward,  so  that  the  two  meet  over  the  posterior  belly  of  the  digastric 
muscle  (Fig.  260).  The  respective  ends  of  the  nerve  trunk  are  then 
united  by  means  of  a  small  curved  needle  and  catgut.  The  sutures, 
four  in  number,  should  include  only  the  sheaths  of  the  nerves.  It  is 
needless  to  say  that  the  stumps  of  each  nerve  should  have  been  pre- 
viously cut  squarely  off  so  that  the  two  ends  can  be  most  accurately 
coaptated  and  retained  in  contact  with  each  other  until  union  has 
occurred,  because  the  success  of  the  operation  depends  entirely  upon 
the  accuracy  with  which  this  step  is  performed.  Should  infection  of 
the  wound  occur  and  suppuration  in  or  about  the  grafted  nerve  take 


CHRONIC   MASTOIDITIS 


407 


place  during  the  process  of  union,  failure  to  restore  the  function  would 
most  certainly  result.  Every  precaution  must,  therefore,  be  taken,  both 
in  the  preparation  for  and  the  performance  of  the  operation  itself,  to 
the  end  that  the  most  perfect  asepsis  is  secured.  The  external  wound 


FIG.  260. — FRAZIER'S  OPERATION  FOR  ANASTOMOSIS  OF  THE  FACIAL  WITH  THE  HYPOGLOSSAL  NERVE. 

i,  String  of  the  central  segment  of  the  facial  nerve;  2,  spinal  accessory  nerve;  3,  reflected  portion  of  the 
hypoglossal  nerve;  4,  descendens  noni;  5,  occipital  artery;  6,  internal  carotid;  7,  parotid  gland  drawn  forward 
with  a  retractor;  8,  digastric  muscle;  9,  course  of  hypoglossal  nerve  before  it  was  reflected;  10,  external  carotid 
artery  (Frazier). 

should  be  closed  at  once  because  a  primary  union  of  every  tissue  is 
desirable. 

Results. — Complete  restoration  of  the  function  of  the  facial  nerve 
as  exhibited  by  the  movements  it  is  capable  of  imparting  to  the  muscles 
of  the  face  which  it  supplies  has  not  as  yet  been  attained  by  this  opera- 
tion. When  successfully  performed,  however,  two  grades  of  improve- 
ment may  be  expected,  as  follows:  In  the  first  the  muscle-tone  of  the 


408  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

affected  side  of  the  face  is  so  improved  that  the  muscles  are  no  longer 
flaccid  and  the  facial  expression  during  a  state  of  repose  is  no  longer 
asymmetrical.  A  still  further  improvement  may  take  place  in  time, 
whereby  the  patient  will  be  able  to  control  certain  groups  of  facial 
muscles,  as,  for  example,  those  that  close  the  eye,  those  that  wrinkle 
the  forehead,  or  those  that  pucker  the  lips,  as  in  whistling.  This  latter 
improvement  is  most  gratifying  to  the  patient,  and  can  be  secured  pro- 
vided the  antiseptic  and  surgical  technic  of  the  operation  is  not  faulty, 
and  the  grafting  has  not  been  delayed  until  the  peripheral  fibers  of  the 
facial  nerve  have  degenerated  and  the  muscles  supplied  by  them  are 
atrophied. 


CHAPTER  XXXI 

THE    INTRACRANIAL    COMPLICATIONS   OF    SUPPURA- 
TIVE  PROCESSES  WITHIN  THE  TEMPORAL  BONE 

General  Considerations. — Mention  has  already  been  made  in  the 
several  sections  of  this  work  which  deal  with  the  suppurative  aural  dis- 
eases of  the  fact  that  when  an  infection  of  the  pneumatic  spaces  of  the 
temporal  bone  has  once  taken  place,  an  extension  of  the  same  to  the 
meninges,  brain,  or  lateral  sinus  may  occur  at  any  subsequent  time.1 
When  we  examine  this  bone  in  section  and  note  the  very  intimate  relation 
its  cellular  interior  bears  to  the  sigmoid  sinuses  and  brain  coverings,  and 
then  recall  the  frequency  and  persistency  with  which  the  mastoid  cells 
suppurate,  we  are  led  to  marvel  not  that  intracranial  complications  fre- 
quently occur,  but  that  they  do  not  take  place  much  more  often  than 
is  at  present  recognized.  (Examine  Figs.  261  to  264,  and  note  especially 
the  very  thin  osseous  partitions  which  separate  the  cells  from  the  intra- 
cranial contents.) 

As  a  result  of  the  examination  in  section  of  100  temporal  bones 
the  author  found  that  the  tegmen  antri,  tegmen  tympani,  and  tegmen 
celluli,  which  form  the  compact  but  exceedingly  thin  roof  of  the 
pneumatic  temporal  structure  and  a  small  portion  of  the  floor  of  the 
brain,  are  on  the  average  not  more  than  one-third  as  thick  as  is  the  bony 
cortex  which  separates  the  mastoid  cells  from  the  exterior  surface  of 
this  portion  of  the  skull.  There  are  some  exceptions  to  this  statement, 
occurring  chiefly  in  those  cases  in  which  there  were  one  or  more  large 
pneumatic  cells  at  the  tip  of  the  mastoid  process  (Fig.  232),  in  which 
instances  the  shell  of  bone  separating  the  air  space  from  the  digastric 
fossa  was  about  the  same  thickness  as  the  tegmen.  It  follows,  there- 
fore, that  in  the  average  case  of  suppuration  occurring  within  the 
temporal  labyrinth  of  cells,  that  the  pus  when  confined  under  pressure, 
would  meet  with  much  less  resistance  when  pursuing  a  brainward 
direction  than  it  would  in  traveling  in  an  outward  direction,  provided, 

1  Concerning  this  point  C.  R.  Holmes  states:  That  after  excluding  cerebrospinal  and 
tuberculous  meningitis  and  trauma  and  a  small  proportion  of  cases  that  may  have  had 
their  origin  from  the  head  and  neck  outside  of  the  nasopharynx  and  sinuses,  practically 
all  cases  of  inflammation  of  the  brain  and  its  membranes  are  caused  by  extension  of  puru- 
lent inflammation  from  the  ear  and  from  the  nose  and  its  accessory  sinuses. 

409 


4io 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


FIG.  261. — PERPENDICULAR  SECTION  OF  TEMPORAL  BONE  IN  A  PLANE  POSTERIOR  TO  THE  TYMPANIC  CAVITY 

AND  MASTOID  ANTRUM. 
Note  the  very  thin  tegmen  and  the  comparatively  thick  cortex. 


Tegmen  celluli 
Middle  cerebral  fossa 


Large  cell  internal  and 
posterior  to  canal  for 
facial  nerve 

Digastric 
groove 


Large  cell  of  tip 


FIG.  262. — VERTICAL  SECTION  OF  TEMPORAL  BONE  ON  A  PLANE  BETWEEN  THE  MASTOID  ANTRUM  AND  SIG- 

MOID  GROOVE. 

The  specimen  shows  a  thick  cortex  and  a  thin  tegmen.     The  pneumatic  spaces  extend  back  almost  to  the  occipi- 
tal bone  and  one  very  large  cell  is  internal  to  the  digastric  groove  and  facial  nerve. 

of  course,  that  the  meninges  on  the  cranial  side  of  the  tegmen  and 
the  soft  tissues  covering  the  outer  cortex  of  bone  are  not  considered 
factors  in  the  resistance.  Experienced  mastoid  operators  are  aware  that 


COMPLICATIONS  OF   SUPPURATIVE    PROCESSES   IN   TEMPORAL    BONE   411 

perforation  of  the  bone  outward  often  takes  place,  whereas,  perforation 
through  the  tegmen  into  the  cranial  cavity  or  into  the  groove  of  the  sinus 


Thick  external 
attic  wall 


FIG.  263. — SECTION  OF  SKULL  IN  PLANK  OF  EXTERNAL  AUDITORY  MEATUS  AND  TYMPANIC  CAVITY. 
Note  thinness  of  tegmen  tympani  and  thickness  of  bone  external  to  tegmen  over  external  auditory  canal. 

is  perhaps  more  rarely  observed.     This  being  contrary  to  what  should 
be  expected  concerning  the  direction  of  the  perforation  in  view  of  the 

Tegmen  celluli 

\  Cerebellar  semi- 
f  circular  canals 

Internal  audi- 
tory meatus 

Floor  of  vestibule 


: 


Jugular  bulb 


FIG.  264. — SHOWS  FIRST,  A  PAPER-THIN  TEGMEN  CELLULI  AND  SECOND,  THE  SOLID  AND  THICK  BONE  IN 

WHICH  THE  VESTIBULE  AND  SEMICIRCULAR  CANALS  LIE. 

Compare  thickness  of  the  tegmen  with  that  of  cortex. 

anatomic  facts  stated  above,  it  must  be  that  either  the  erosion  through 
the  tegmen  or  sigmoid  groove  is  sometimes  overlooked  by  the  operator 


412  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

or  else  the  resistance  of  the  dura  mater  to  the  invasion  of  pus  is  greater 
than  that  of  the  periosteum.  It  is  highly  probable  that  a  greater  number 
of  perforations  take  place  into  the  cranial  cavity  than  are  ever  recognized, 
because  these  patients  very  often  die  without  a  correct  diagnosis  having 
been  made,  without  operation  or  post  mortem,  and  the  cause  of  death  in 
such  cases  is  usually  reported  as  meningitis.  Too  often  the  physician 
in  charge  has  had  no  suspicion  that  the  cause  of  the  death  had  its  origin 
in  a  suppurating  ear. 

The  advancement  of  medicine  is  perhaps  nowhere  better  shown  than 
in  the  improvement  that  has  taken  place  in  the  methods  of  diagnosis  and 
treatment  of  suppurative  aural  diseases  and  their  complications,  for  in 
his  earnest  efforts  to  cure  these  affections  the  otologist  has  of  late  followed 
the  necrosing  processes  into  whatever  depth  or  direction  they  may  have 
led,  and  thus  he  has  discovered  the  origin  of  and  has  developed  a  treat- 
ment for  a  class  of  diseases  that  has  created  an  entirely  new  field  in 
otology,  one  which  lies  beyond  the  ear,  but  which  is  nevertheless  so 
inseparably  connected  with  aural  affections  that  it  should  be  included 
in  the  domain  of  otology. 

Frequency. — Hassler  states  that  of  81,684  ear  cases  treated  there 
were  116  deaths  due  to  intracranial  extension.  Of  these  48  died  of  sinus 
thrombosis,  28  of  cerebral  abscess,  and  40  of  meningitis.  Korner  reports 
that  in  115  necropsies  after  death  from  ear  extension,  41  died  from  sinus 
thrombosis,  43  from  brain  abscess,  and  31  from  meningitis. 

In  an  exhaustive  article  on  the  statistics  of  this  subject,  Pitt  reports 
that  of  9000  autopsies  made  in  the  hospitals  of  London,  the  record 
representing  the  consecutive  ones,  and  therefore  was  for  deaths  from  all 
diseases,  just  as  they  naturally  occurred,  57  were  due  to  suppurations 
in  the  temporal  bone,  or  i  such  death  in  every  158  running  hospital 
cases,  distributed  as  follows:  48  died  of  sinus  thrombosis,  28  of  cerebral 
abscess,  40  of  meningitis. 

Korner,  of  Rostock,  who  has  compiled  most  extensive  statistics  on 
this  subject,  shows  that  more  than  6  of  every  1000  deaths  from  ear 
diseases  are  the  result  of  brain  abscess.  Jansen  found  abscess  of  the 
brain  once  in  2650  cases  of  acute  middle-ear  suppuration,  whereas, 
the  same  author  found  6  cases  of  brain  abscess  in  2500  cases  of  chronic 
aural  suppuration. 

The  records  of  the  Manhattan  Eye  and  Ear  Infirmary  show  that  of 
12,744  cases  of  suppurative  aural  discharge  treated  from  1895  to  I9°5' 
60  were  complicated  by  intracranial  extension.  Of  these  60  cases,  23 
were  affected  by  a  sinus  thrombosis,  30  by  meningitis,  and  7  by  brain 
abscess. 


COMPLICATIONS    OF    SUPPURATIVE   PROCESSES    IN   TEMPORAL    BONE    413 

The  cause  of  the  several  intracranial  diseases  which  result  from 
aural  suppuration  is  the  same  for  each  of  the  diseases — namely,  the 
entrance  into  the  cerebral  or  cerebellar  fossae  of  infectious  products  from 
the  suppurating  foci  within  the  temporal  bone.  The  extension  may  take 
place  either  directly,  as  in  instances  where  the  necrosis  spreads  from  the 
mastoid  interior,  uncovers  the  dura  at  some  neighboring  point  (as  in 
Fig.  226),  and  thus  admits  the  pathogenic  fluid  directly  into  the  cranial 
cavity;  or  the  septic  material  may  be  indirectly  carried  to  the  meninges 
or  to  the  sigmoid  sinus  contents  through  the  medium  of  the  intercom- 
municating veins,  in  which  instance  there  is  no  visible  path  between 
the  infected  area  of  the  temporal  bone  and  that  resulting  within  the 
cranial  cavity.  Oppenheimer,  (Medical  Record,  Aug.,  1902),  in  a  study 
of  the  venous  system  of  the  temporal  bone,  with  a  view  of  establishing 
the  part  these  vessels  play  in  the  transmission  of  pathogenic  material 
from  the  diseased  cellular  structure  of  the  bone  to  the  cranial  con- 
tents, states  that  it  is  his  belief  that  such  transmission  is  in  the 
majority  of  cases  directly  through  an  opening  provided  by  previous 
necrosis  of  the  intervening  parts;  nevertheless,  meningitis,  sinus  throm- 
bosis, and  brain  abscess  are  often  the  result  of  the  carriage  of  septic 
matter  by  means  of  these  venous  channels.  Infection  of  any  portion  of 
the  cerebral  contents  through  the  medium  of  the  vascular  channels  most 
frequently  follows  an  acute  suppurative  process  within  the  temporal  air 
spaces,  whereas  the  direct  extension  of  the  sepsis  through  necrotic  or 
carious  channels  is  more  frequently  met  with  in  chronic  cases.  When 
the  dura  mater  has  been  exposed  by  the  destruction  of  the  thin  osseous 
lamella  against  which  it  lies,  the  pus  is  thereby  admitted  to  direct  contact 
with  this  brain  structure.  The  localized  meningitis  which  follows 
results  in  the  production  of  granulation  tissue  which  no  doubt  frequently 
forms  an  effectual  barrier  against  the  further  invasion  of  the  pus,  and 
thus  the  further  spread  of  the  infection  is  limited.  The  dura  becomes 
thickened  over  the  exposed  area  and  adhesions  take  place  over  its  inner 
surface  to  the  arachnoid  and  over  its  outer  surface  to  the  edges  of  the 
fistulous  opening  in  the  adjacent  part  of  the  temporal  bone.  By  this 
means  leptomeningitis  is  prevented  on  the  one  hand  and  pachymenin- 
gitis  on  the  other.  Because  of  the  efficient  protection  offered  by  these 
adhesions  and  by  the  thickened  dura  a  perforation  may  exist  through 
the  tegmen  or  into  the  sigmoid  groove  for  a  long  time  without  the 
occurrence  of  symptoms  indicative  of  its  presence  further  than  the 
usual  aural  discharge.  In  infants  and  young  children  infection  of  the 
temporosphenoidal  lobe  of  the  brain  may  occur  as  a  result  of  the 
passage  of  the  pathogenic  fluids  from  the  middle  ear  or  mastoid  an- 


414  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

trum  directly  through  the  squamopetrosal  suture  (Fig.  10),  which  in 
early  life  is  filled  only  with  soft  tissues  through  which  pass  the  numer- 
ous veins  connecting  the  cavity  of  the  middle  ear  with  the  cerebral 
structures. 

The  symptoms,  diagnosis,  and  treatment  are  best  given  separately 
in  the  discussion  of  each  individual  intracranial  disease. 


CHAPTER  XXXII 
INTRACRANIAL  COMPLICATIONS  (Continued) 

SINUS   PHLEBITIS   AND   SINUS  THROMBOSIS 

THIS  is  the  most  frequent  of  the  intracranial  complications  and, 
like  the  others,  occurs  oftener  than  has  heretofore  been  recognized. 
The  occurrence  of  a  sinus  thrombosis  in  any  given  case  of  suppura- 
tion of  the  mastoid  cells  must  depend  largely  upon  the  location  of 
such  cells  in  relation  to  the  sigmoid  sinus  groove.  Hence,  if  the  cells 
are  large  and  are  separated  from  the  groove  of  the  sinus  by  only  the 


Middle  fossa 


Mastoid  cells   E-,^^    •  B   Sigmoid  sulcus 


Large  tip  cell 


FTG.  265.- — SHOWS  THIN  WALL  BETWEEN  SIGMOID  SINUS  AND  MASTOID  CELLS. 
(Warren  Museum,  Harvard  Medical  School.     J.  Orne  Green  Collection.) 

thinnest  osseous  partitions,  as  shown  in  Figs.  265  and  266,  a  sinus 
infection  would  be  very  probable  in  case  of  mastoid  suppuration, 
whereas  if  the  mastoid  process  is  eburnated,  as  in  the  illustration 
shown  in  Fig.  241,  it  is  scarcely  probable  that  sinus  infection  would 
ever  occur  as  a  result  of  mastoiditis. 

Pathology. — Sinus  thrombosis  is  usually  secondary  to  diseased  bone 
overlying  the  sinus  (see  chapter  on  Bacteriology).     The  most  common 

415 


416 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


site  for  the  infection  is  the  sigmoid  portion  of  the  lateral  sinus  (Fig. 
267;  see  also  Figs.  22410227).  The  diseased  bone  or  extension  of  thrombi 
through  small  vessels  leading  from  the  diseased  focus  to  the  sinus  causes 
a  sinus  phlebitis  (Korner),  and  the  phlebitis  may  set  up  a  mural  throm- 


Internal  auditory 
meatus 


FIG.  266. — LARGE  CELL  INTERNAL  TO  DIGASTRIC  GROOVE. 
Note  very  thin  bony  partition  between  cell  and  sinus. 

bus  which  continues  to  grow  either  with  the  blood  stream  or  against  it. 
This  thrombus  is  always  infectious,  although  the  newly  formed  ad- 
vancing end  of  the  clot  may  be  sterile.  The  thrombus  may  cause 


Middle  cerebral 
fossa 


Carious  openings 
into  sigmoid 
groove 


FIG.  267. — POSTERIOR  VIEW  OF  RIGHT  TEMPORAL  BONE. 

Caries  extending  from  the  mastoid  into  the  sigmoid  sinus.      (Warren   Museum,   Harvard   Medical   School. 

J.  Orne  Green    Collection.) 

sudden  obliteration  or  may  gradually  block  the  sinus.  The  thrombus 
may  extend  backward  to  the  torcular  Herophili  and  even  into  the  lateral 
sinus  on  the  other  side.  The  thrombus  may  extend  into  the  superior 
or  inferior  petrosal  sinuses  (Figs.  268  and  269),  to  the  cavernous  sinus, 


INTRACRANIAL   COMPLICATIONS 


417 


and  thence  to  the  ophthalmic  vein.  Extension  to  the  jugular  bulb  and 
the  internal  jugular  vein,  with  involvement  of  the  lymphatic  glands 
along  the  vein,  may  take  place.  Thrombosis  may  extend  from  the  in- 
ternal jugular  into  the  facial  vein.  Extension  through  the  mastoid 
emissary  vein  or  through  the  anterior  condyloid  vein  may  also  occur  (see 
Fig.  269). 

Optic  neuritis  occurs  in  35  to  50  per  cent,  of  cases  according  to 
Jansen.     Paralysis  of  the  hypoglossal  nerve,  through  pressure  on  the 


FIG.  268. — THE  SYSTEM  OF  VENOUS  INTRACRANIAL   SINUSES  AND  CONNECTIONS  WITH  THE  VEINS  OF  THE 

NECK. 
Compare  with  Fig.  269. 

condyloid  vein  as  the  nerve  comes  through  the  anterior  condyloid  fora- 
men, may  occur.  Thrombosis  of  the  jugular  bulb  may  cause  pressure 
upon  adjoining  structures,  and  thus  paralysis  of  the  vagus,  spinal 
accessory,  or  the  glossopharyngeal  may  result.  Thrombosis  of  the 
cavernous  sinus,  with  extension  to  the  ophthalmic  vein,  always  gives 
positive  ophthalmoscopic  pictures.  There  may  be  paralysis  of  the 
abducens,  trochlearis,  oculomotorius,  or  trigeminus  nerves,  either  a 

27 


418  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

single  nerve  or  more  than  one  of  the  above  being  affected  in  the  same 
case. 

Diagnosis  and  Symptoms. — The  formation  of  a  clot  in  the  sigmoid 
sinus  is  attended  by  symptoms  that  vary  so  widely  in  different  cases 
that  diagnosis  in  the  early  stages  is  always  difficult  and  often  impossible. 
That  a  diagnosis  should  be  made  in  each  case  at  the  earliest  possible 
moment  is  a  matter  of  great  importance  to  the 'welfare  of  the  patient. 
The  attendant  upon  any  case  of  suppurative  aural  disease  should  be 
ever  alert  to  the  possibility  of  a  sinus  infection,  and  should,  therefore, 
take  note  of  all  unusual  symptoms  in  order  that  he  may  immediately 
call  to  his  aid  every  diagnostic  means,  to  the  end  that  recognition  of 
the  sinus  affection  may  be  made  before  the  infection  has  been  dissemi- 
nated by  the  blood-current  to  distant  parts  of  the  body  and  before  a 
general  sepsis  has  been  established. 

Since  sinus  thrombosis  nearly  always  results  from  an  existing  aural 
infection,  all  the  symptoms  that  usually  accompany  a  suppurating  ear 
may  be  present.  Except  in  those  acute  cases  where  infection  of  the 
jugular  bulb  takes  place  through  the  floor  of  the  middle  ear,  there  is  a 
preceding  mastoiditis,  the  symptoms  of  which  may  obscure  or  even  be 
entirely  mistaken  for  those  of  the  lateral  sinus  thrombosis.  Pain, 
swelling,  and  tenderness  in  the  mastoid  region,  while  present  in  some 
cases  of  lateral  sinus  thrombosis,  are  not  of  themselves  a  diagnostic 
indication  that  the  sinus  is  involved. 

The  symptoms  of  sinus  thrombosis  are  typic  and  atypic.  Of 
the  typic  manifestations  the  behavior  of  the  temperature  is  of  greatest 
diagnostic  importance.  In  any  case  of  suppurative  middle-ear  disease 
the  temperature  may  be  normal  or  only  slightly  elevated,  but  should 
infection  of  the  sinus  occur  it  will  at  once  rise  to  102°,  104°,  106°  F.,  and 
not  infrequently  higher,  and  after  a  short  time  will  drop  to  normal  or 
near  the  normal.  One  or  more  such  fluctuations  may  occur  during  the 
twenty-four  hours,  depending  entirely  upon  the  rapidity  with  which 
the  septic  matter  from  the  diseased  vessel  is  thrown  into  the  general 
system.  The  rise  in  temperature  is  usually  preceded  by  a  chill,  and  the 
fall,  especially  if  the  disease  is  well  advanced,  is  followed  by  exhaustive 
sweating.  More  than  one  chill  may  occur  in  the  twenty-four  hours, 
the  character  of  which  may  amount  to  a  pronounced  rigor  or  may 
be  so  mild  that  it  will  be  recognized  as  only  a  coldness  of  the  extremities; 
the  fact  that  a  chill  has  occurred  may  pass  unobserved  by  the  attendants 
and  may  only  be  learned  by  inquiry  directed  to  the  patient.  In  all 
suppurative  aural  cases  that  run  a  fluctuating  temperature  the  develop- 
ment of  chilly  sensations  should  always  be  looked  for  by  the  nurse, 


16     15 


FIG.  269. — KEY  TO  TRANSPARENT  HEAD.    Y,  Z,  REID'S  BASE-LINE 

i,  Ophthalmic  veins;  2,  cavernous  sinus;  3,  inferior  petrosal  sinus;  4,  Eustachian  tube;  5,  superior  longitudinal  sinus;  6,  occip- 
ital sinus;  7,  lateral  sinus;  8,  mastoid  vein;  9,  mastoid  cells;  10,  course  of  facial  nerve;  u,  mastoid  antrum;  12,  superior  petrosal 
sinus;  13,  center  of  external  auditory  meatus;  14,  membrana  tympani;  15,  internal  jugular  vein;  1 6,  internal  carotid  artery. 

A ,  B,  Points  of  election  for  trephining  the  skull  in  exploration  of  the  cerebral  structures  adjoining  the  tegmen  antri,  legmen 
tympani,  and  the  neighboring  surface  of  the  petrous  portion  of  the  temporal  bone.  (See  Fig.  277.)  Point  A  lies  i  inch  above 
Reid's  base-line  at  the  center  of  the  auditory  meatus.  Point  B  lies  ij  inches  above  Reid's  base-line  and  i  J  inches  posterior  to  the 
center  of  the  external  auditory  meatus.  C  is  a  point  on  Reid's  base-line  J  inch  posterior  to  the  center  of  the  external  auditory 
meatus.  It  lies  over  the  sigmoid  sinus  when  the  latter  follows  the  normal  course.  This  would  be  the  point  of  election  for  removing 
the  mastoid  cortex  in  case  it  is  desirable  to  enter  the  sinus  without  first  having  performed  a  mastoid  exenteration.  The  very  variable 
course  of  the  sigmoid  sinus  may  in  any  given  case  place  it  either  anterior  or  posterior  to  point  C.  Point  D  represents  the  posterior 
limit  of  exploratory  operation  on  the  skull  over  the  cerebellar  fossa.  A  point  on  Reid's  base-line,  midway  between  points  C  and  D, 
or  at  a  point  i$  inches  posterior  to  the  center  of  the  auditory  meatus  and  i  inch  below  the  base-line,  is  the  one  of  election  for 
opening  the  cerebellar  fossa.  5,  Fissure  of  Sylvius.  R,  Fissure  of  Rolando.  Note  the  position  of  the  several  sensory  and  motor 
areas  of  the  brain  located  along  the  course  of  these  fissures. 


FIG.  269. — TRANSPARENT  HEAD,  SHOWING  SYSTEM  OF  VENOUS  SINUSES,  THE  SURGICAL  RELATION  OF  THE 
STRUCTURES  OF  THE  TEMPORAL  BONE,  AND  THE  MOTOR  AND  SENSORY  AREAS  OF  THE  HRAIN. 


INTRACRANIAL   COMPLICATIONS  419 

and  frequent  inspection  of  the  hands,  feet,  and  knee-caps  should  be 
made  with  a  view  of  ascertaining  this  important  information,  because 
the  mere  chilly  sensations  are  as  important  in  a  diagnostic  way  as  are 
the  pronounced  chills. 

Severe  sweating  is  not  always  present,  but  in  the  typic  case  is 
frequent  and  often  most  pronounced.  During  the  earlier  stages  of  the 
vein  involvement  it  may  attract  but  little  or  no  attention,  but  as  the 
general  infection  becomes  more  marked,  the  amount  and  persistence 
of  the  perspiration  becomes  one  of  the  most  prominent  features  of  the 
disease,  since  it  is  often  sufficient  in  quantity  to  wet  the  bedclothing  and 
thoroughly  drench  the  patient.  At  first  the  sweating  occurs  only  during 
the  subsidence  of  the  temperature,  but  in  the  worst  cases  it  may  continue, 
though  lessened,  throughout  both  the  highest  and  lowest  temperatures. 
The  patient,  thus  exhausted  by  excessive  body  heat  and  rapid  loss  of  fluid, 
becomes  quickly  emaciated  and  presents  a  most  typic  septic  appear- 
ance. 

Pain  on  the  affected  side  of  the  head  is  usually  present  and  may 
be  localized  in  the  mastoid  or  occipital  regions.  The  pain  may  also  be 
referred  to  the  neck  in  case  there  is  an  accompanying  cellulitis  of  the 
cervical  tissues;  or  in  the  event  that  the  cervical  glands  have  become 
infected  and  are  consequently  enlarged  and  inflamed.  This  infection 
of  the  lymphatic  glands  and  cellular  tissue  of  the  neck  may  give  rise 
to  a  general  tumefaction  of  the  affected  side,  all  the  structures  being 
finally  massed  together  by  the  inflammatory  process.  Should  resolution 
not  promptly  take  place,  a  deep  abscess  may  be  the  ultimate  result. 
This  general  infection  and  infiltration  of  the  cervical  tissues  gives  rise 
to  a  condition  that  was  once  described  as  a  sausage-like  lump  in  the 
neck,  to  which  condition  great  diagnostic  significance  was  attached. 
Such  a  symptom  is  observed  only  in  the  later  stages  of  sinus  thrombosis, 
and  if  the  case  has  been  under  observation  from  the  first  a  diagnosis 
of  the  true  condition  should  have  been  made  long  before  the  appearance 
of  the  neck  infiltration. 

The  pulse-rate  varies  with  the  temperature.  When  the  fever  is 
only  moderate  the  rate  may  not  greatly  exceed  100,  but  when  the  tem- 
perature rises  to  104°  or  1 06°  F.  the  pulse-rate  may  rise  to  150  or  180  per 
minute.  It  should  not  be  forgotten  in  this  connection  that  sinus  throm- 
bosis and  brain  abscess  may  both  be  present  in  the  same  individual,  and 
that  when  such  is  the  case  the  influence  of  the  abscess  upon  the  circula- 
tion will  lower  the  pulse-rate  to  normal  or  even  less. 

The  mentality  of  the  patient  is  unaffected  in  the  beginning  and 
often  remains  so  during  the  course  of  the  disease.  In  many  cases, 


420  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

however,  drowsiness  comes  on  as  exhaustion  increases  and  the  patient 
finally  dies  in  a  coma. 

Vomiting  is  a  symptom  to  be  expected  in  any  intracranial  com- 
plication. It  is  present  at  some  stage  of  sigmoid  sinus  thrombosis 
in  the  large  majority  of  cases.  The  vomiting  is  of  a  cerebral  character 
and  usually  takes  place  without  reference  to  the  time  of  taking  food. 

Constipation  is  the  rule  in  the  early  stages,  but  as  systemic  infection 
becomes  marked,  and  when  nature  is  making  every  effort  to  eliminate 
the  poison,  a  diarrhea  often  accompanies  the  profuse  sweating  that  has 
already  been  mentioned. 

Vertigo  is  seldom  present  in  uncomplicated  cases.  Epileptiform 
convulsions  have  been  several  times  reported.  In  from  one-fourth  to 
one-third  of  all  cases  of  sinus  thrombosis  there  are  intracranial  changes 
which  are  discoverable  by  ophthalmoscopic  examination,  and  when 
other  evidences  of  the  suspected  sinus  disease  are  not  sufficient  for 
diagnosis  the  eye  findings  will  prove  most  helpful. 

During  the  later  stages  of  the  sinus  thrombosis  the  septic  clot  within 
the  vein  may  disintegrate  and  particles  of  the  same  may  be  cast  off 
into  the  general  blood  stream.  Emboli  thus  formed  are  carried  first 
to  the  right  side  of  the  heart  and  thence  to  the  lungs,  where  they  lodge 
in  the  smaller  pulmonary  vessels  and  set  up  new  foci  of  infection  with 
quickly  resulting  pneumonia.  This  occurrence  at  first  gives  rise  to  a 
dry  and  irritating  cough  that  is  most  trying  to  the  already  wasted  energies 
of  the  patient,  who  frequently  dies  at  this  period  from  the  multiplicity 
and  severity  of  his  ailments.  Occasionally,  however,  the  infection  is 
carried  through  the  lungs  into  the  arterial  circulation,  where  it  is  finally 
deposited  in  one  of  the  extremities,  as  a  result  of  which  multiple  abscesses 
quickly  form  and  death  finally  takes  place  from  the  general  pyemia 
which  occurs. 

Atypic  Cases. — A  number  of  cases  have  recently  been  reported  in 
which  few,  sometimes  only  one,  and  in  several  cases  not  a  single  one  of 
the  above  symptoms  was  present,  although  exposure  of  the  vein  at  the 
operation  or  post-mortem  examination  has  proved  without  doubt  the 
existence  of  a  thrombosed  sinus.  Although  the  behavior  of  the  tem- 
perature is  regarded  as  one  of  the  most  reliable  symptoms  of  sinus 
thrombosis,  instances  are  recorded  in  which  the  temperature  has  re- 
mained normal  for  a  considerable  length  of  time  after  the  thrombosis 
had  taken  place.  While  large  statistics  as  to  the  frequency  with  which 
a  chill  occurs  are  not  available,  the  records  at  hand  indicate  that  a 
decided  rigor  is  not  a  symptom  in  over  50  per  cent,  of  the  cases.  Chilly 
sensations  are,  however,  present  at  some  time  during  the  progress  of 


INTRACRANIAL   COMPLICATIONS  421 

the  disease,  so  that  it  may  be  stated  as  probable  that  either  a  decided 
chill  or  chilly  sensation  is  a  symptom  in  80  or  90  per  cent,  of  all  in- 
stances of  sinus  thrombosis.  It  should  be  remembered  that  the  patient 
may  not  complain  of  the  chilly  sensations  and  that,  therefore,  it  may  not 
be  known  that  they  have  occurred  unless  the  attendant  has  frequently 
sought  information  on  this  point. 

In  the  atypic  case  the  temperature  may  suddenly  rise  from  normal 
or  near  the  normal  to  104°,  105°,  or  106°  F.,  and  remain  steadily  at  that 
point  or  remit  but  slightly.  Sweating  will  likely  not  occur  and  no 
other  symptom  be  present  except  the  high  continuous  fever  and  the 
mastoiditis.  If,  as  is  sometimes  the  case,  this  latter  gives  rise  to  external 
symptoms,  the  diagnosis  cannot  be  readily  made  and  the  patient  must 
be  watched  and  frequently  examined  for  additional  information. 

Since  it  is  highly  essential  to  efficient  treatment  that  the  diagnosis 
should  be  made  in  the  early  stage  of  the  thrombosis,  advantage  must 
be  taken  of  every  available  aid  to  this  end.  The  blood-count  should 
be  early  made  and  afterward  repeated  in  all  suspected  but  doubtful 
cases.  A  high  leukocytosis  is  considered  by  many  to  be  of  value  and, 
certainly  when  demonstrated  in  the  presence  of  other  suspicious  symp- 
toms, is  helpful.  A  high  percentage  of  polymorphonuclear  cells  also 
aids  in  the  diagnosis  because  the  presence  of  this  blood  condition 
would  indicate  the  existence  of  a  collection  of  pus  in  some  part  of  the 
body,  and  with  all  other  symptoms  pointing  to  sinus  involvement,  this 
information  would  be  of  first  value. 

In  infants  and  young  children  the  thrombosis  of  the  jugular  bulb 
may  take  place  as  a  result  of  the  direct  transmission  of  septic  matter 
from  the  middle  ear  through  the  lamella  of  bone  which  separates  the 
tympanic  cavity  from  the  jugular  fossa.  This  osseous  partition  is 
always  very  thin  in  the  infant,  sometimes  no  thicker  than  parchment. 
Rarely  a  dehiscence  exists  in  the  bone,  and  in  such  cases  the  mucous 
membrane  of  the  middle  ear  and  the  wall  of  the  jugular  bulb  lie  in 
immediate  contact.  In  every  instance,  therefore,  of  suppurative  otitis 
media  in  the  infant  it  would  seem  an  easy  matter  for  pathogenic  material 
to  find  its  way  into  the  jugular  bulb  without  following  the  usual  route 
through  the  mastoid  antrum  and  cells  and  finally  into  the  sigmoid  sinus. 

Children  so  affected  present  atypic  symptoms  and  unless  the 
attending  physician  is  aware  of  the  possibility  of  the  occurrence  of 
jugular  bulb  thrombosis  in  any  case  of  middle-ear  suppuration  in  early 
life,  the  developing  sinus  thrombosis  may  be  entirely  overlooked.  The 
most  important  symptom  denoting  jugular  thrombosis  in  the  infant 
is  a  sudden  rise  in  the  temperature  from  normal  or  near  the  normal 


422  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

to  104°,  105°,  or  106°  F.,  after  which  the  decline  is  as  precipitous  as 
the  rise.  The  fluctuations  in  temperature  occur  with  some  regularity. 
The  child  is  fretful  and  shows  evidence  of  severe  illness  during  the 
height  of  the  fever,  but  during  the  remissions,  especially  of  the  first  few 
days,  it  looks  well,  plays  with  its  toys,  asks  for  food,  and  in  every  way 
deceives  all  concerned  as  to  the  gravity  of  the  illness.  The  pulse-rate 
varies  with  the  temperature,  and  is  high  when  the  fever  is  up,  but  ap- 
proaches the  normal  when  the  fever  recedes.  A  distinct  chill  is  seldom 
present,  but  if  examination  of  the  hands  and  feet  of  the  child  be  made 
just  when  the  temperature  begins  to  rise  it  will  usually  be  found  that 
they  are  cold.  After  several  days  the  patient  becomes  more  prostrate, 
the  tongue  becomes  white  and  dry,  and  the  child  takes  on  a  septic 
appearance  that  may  be  accompanied  by  a  pneumonia  which  quickly 
terminates  in  death. 

Excepting  the  advanced  and  typic  cases  of  sinus  thrombosis, 
the  diagnosis  is  always  attended  with  difficulty.  The  disease  may  be 
mistaken  for  malaria,  typhoid  fever,  pneumonia,  and  in  children,  for 
digestive  disturbances.  The  chill,  high  fever,  remission  of  the  tem- 
perature and  interval  of  profuse  perspiration  which  accompanies  it 
may  be  identical  with  that  of  a  typic  attack  of  malaria.  An  examina- 
tion of  the  blood  and  a  determination  of  the  presence  of  the  plasmoidum 
malariae  would  be  necessary  and  helpful  under  such  circumstances. 
A  central  pneumonia  sometimes  complicates  a  discharging  ear,  in 
which  case  the  chill  and  sudden  rise  of  temperature  produced  by  the 
lung  involvement  may  be  very  misleading,  for  it  is  admitted  that  this 
form  of  pneumonia  cannot  always  be  diagnosticated  by  means  of  auscul- 
tation and  percussion,  and  that  therefore  the  expectoration  of  rusty 
sputum  must  be  awaited  to  determine  the  exact  nature  of  the  ailment. 
The  course  of  typhoid  fever  during  the  first  week  presents  many  symp- 
toms that  are  almost  identical  with  those  of  sinus  thrombosis  and,  when 
occurring  in  any  case  which  has  a  suppurating  ear,  might  prove  very 
misleading;  and  here  again  blood  tests  may  give  information  which, 
when  carefully  compared  with  all  other  obtainable  facts  concerning 
the  case  may,  together,  be  sufficient  to  enable  the  diagnostician  to  say 
that  it  is  clearly  the  one  or  the  other  disease.  If  dietary  and  digestive 
causes  are  suspected  in  the  child  a  purge  of  castor  oil,  a  limitation  of 
the  food  to  proper  substances,  and  the  administration  of  enzymes  to 
aid  the  feeble  digestive  powers,  should  prove  sufficient  in  most  instances 
to  reduce  the  temperature  to  normal,  where  it  will  permanently  remain 
provided  the  cause  of  the  disturbance  lies  in  the  digestive  tract. 

In  many  instances  of  suspected  sinus  thrombosis  the  otologist  will 


INTRACRANIAL    COMPLICATIONS  423 

do  wisely  to  seek  the  help  of  practitioners  in  other  departments  of 
medicine  before  he  is  willing  to  decide  with  certainty  that  a  patient 
is  suffering  from  a  thrombosed  vein,  because  the  deciding  information 
must  frequently  be  obtained  from  those  who  are  skilled  in  general 
diagnosis — from  the  neurologist,  oculist,  and  laboratory  expert. 

Since  sinus  thrombosis  is  nearly  always  secondary  to  mastoiditis, 
it  is  good  surgery  in  strongly  suspected  cases  to  open  the  mastoid  antrum 
and  cells  in  most  instances,  both  as  a  measure  that  is  necessary  to 
secure  proper  drainage,  and  in  addition,  if  conditions  within  the  bone 
should  justify  it,  of  exploratory  enlargement  of  the  wound  to  the  extent 
of  uncovering  the  sinus  for  purposes  of  immediate  inspection.  If  after 
this  is  accomplished  and  it  is  believed  that  the  sinus  is  not  involved, 
the  wound  may  be  treated  as  hereafter  described  and  the  symptoms 
of  the  patient  be  subsequently  watched  most  carefully,  with  a  view  of 
opening  the  sinus  and  dealing  with  it  in  a  radical  manner  at  any  time 
that  the  evidence  of  its  involvement  seems  sufficient  to  justify  the  measure. 
Exploratory  operations  upon  the  mastoid  and  sinus  must,  therefore,  be 
regarded  among  the  important  diagnostic  measures,  particularly  in  the 
early  stages  of  the  formation  of  the  clot. 


CHAPTER  XXXIII 
INTRACRANIAL  COMPLICATIONS  (Continued) 

TREATMENT  OF  SINUS  INFECTION  AND  SINUS  THROMBOSIS 

THE  treatment  of  sinus  thrombosis  is  almost  wholly  of  a  surgical 
nature.  During  the  early  stages  of  the  disease  when  there  is  yet  doubt 
as  to  the  exact  nature  of  the  trouble,  the  treatment  may  be  conducted 
upon  any  expectant  plan  which  seems  best  suited  for  the  relief  of  the 
symptoms  which  are  present;  but  after  it  has  been  definitely  determined 
that  an  infected  blood-clot  has  formed  in  the  sigmoid  sinus  or  jugular 
bulb,  from  which  it  has  perhaps  extended  downward  into  the  jugular 
vein  itself,  surgical  interference  is  at  once  indicated  for  the  reason  that 
the  continued  discharge  of  septic  material  from  the  seat  of  the  thrombus 
into  the  general  circulation  will  rapidly  add  to  the  already  infected  state 
of  the  patient  and  will  quickly  lessen  his  chances  of  recovery.  The 
objects  of  operative  treatment,  therefore,  should  be  to  rid  the  individual 
at  the  earliest  moment  of  the  obstruction  within  the  vein  and  to  prevent 
as  far  as  possible  the  further  entrance  of  infected  emboli  into  the  general 
circulation. 

The  patient  is  prepared  in  an  exactly  similar  manner  as  for  a  mastoid 
operation,  with  the  additional  precautions  of  shaving  the  hair  for  a 
greater  distance  around  the  ear  and  of  sterilizing  the  neck  of  the 
affected  side  from  the  mastoid  tip  to  the  clavicle. 

The  steps  of  the  operation  that  are  necessary  to  accomplish  the 
desired  ends  are :  First,  the  ablation  of  the  mastoid  and  the  exposure  of 
the  sigmoid  sinus  from  its  knee  downward.  Second,  the  exploration 
of  the  sinus  with  a  view  of  discovering  the  nature  and  extent  of  its  throm- 
bosed  contents.  Third,  the  ligation  and  perhaps  the  removal  of  a 
portion  of  the  jugular  vein  in  the  neck,  provided  the  information  obtained 
during  the  performance  of  the  second  step  is  such  as  to  indicate  with 
certainty  that  the  safety  of  the  patient  depends  upon  the  isolation  of  the 
infected  region  from  the  general  circulation.  Fourth,  the  removal  of 
the  clot  from  the  sinus  and  bulb,  and,  lastly,  the  dressing  of  the  mastoid 
wound,  including  the  sigmoid  sinus. 

In  all  cases  of  sinus  thrombosis  which  occur  as  a  complication  of 
a  coexistent  mastoiditis,  the  first  step  of  the  operation  for  the  relief  of 


INTRACRANIAL    COMPLICATIONS  425 

the  thrombosis  consists  in  opening  the  mastoid  antrum  in  the  usual  way, 
since  this  not  only  rids  the  patient  of  the  original  foci  of  infection  but 
also  provides  an  avenue  through  which  the  sinus  may  be  more  readily 
and  widely  exposed.  In  cases  in  which  the  mastoid  operation  has  been 
previously  performed  and  in  which  the  sinus  thrombosis  has  subse- 
quently developed,  the  mastoid  wound  must  again  be  opened  and  the 
cavity  thoroughly  disinfected.  In  either  case  the  intervening  bone 
between  the  mastoid  cavity  and  the  wall  of  the  sigmoid  sinus  should  be 
removed  to  the  extent  that  i  inch  or  more  of  the  vessel  is  exposed.  It 
may  be  found  necessary  to  uncover  the  sinus  as  far  downward  as  the 
jugular  bulb  or  as  far  backward  as  the  torcular,  but  until  such  extensive 
removal  of  the  bone  in  these  directions  is  seen  to  be  actually  required  by 
the  great  extent  of  the  thrombus,  the  smaller  opening  over  the  vessel,  as 
above  stated,  should  be  considered  sufficient.  It  is,  however,  never 
wise  to  depend  upon  a  trivial  exposure  of  the  sinus,  either  for  diagnostic 
or  operative  purposes,  for  it  is  obvious  that  if  but  a  small  portion  of  the 
course  of  the  vessel  is  uncovered  for  inspection  and  palpation,  that  the 
results  of  both  of  these  important  aids  to  diagnosis  would  be  incomplete 
and  therefore  unreliable.  Moreover  it  is  not  possible  to  carry  out  any 
operative  measures  on  the  sinus  unless  a  sufficiently  wide  exposure  of 
the  vessel  is  provided,  for  the  reason  that  the  very  free  hemorrhage  which 
is  incident  to  opening  the  sinus  cannot  be  controlled  and  any  contained 
clot  could  not  be  safely  or  efficiently  removed  through  the  narrow 
opening  thus  provided.  When  a  small  area  of  the  sinus  wall  has  been 
uncovered  by  the  mallet  and  gouge,  it  is  safest  to  continue  the  removal 
of  the  bone  by  means  of  a  rongeur  or,  preferably,  the  Jansen  forceps 
(Fig.  269).  In  order  to  lessen  the  liability  of  puncturing  the  sinus  with 
the  beak  of  the  instrument,  the  wall  of  this  vessel  should  be  separated 
from  the  bone  for  a  considerable  distance  over  the  course  from  which 
the  bony  covering  is  to  be  removed.  This  may  be  accomplished  by  in- 
serting a  blunt  spatula  between  the  sinus  wall  and  the  overlying  bone 
and  thus  carefully  separating  the  one  from  the  other.  When  this  has 
been  accomplished  the  jaw  of  the  bone  forceps  when  introduced  will 
pass  between  the  two  structures  without  the  necessity  of  applying  undue 
force  directly  to  the  sinus  wall.  A  perisinuous  abscess  may  be  associated 
with  the  thrombosis,  and  when  this  is  the  case  pus  will  pour  from  the 
direction  of  the  sinus  as  soon  as  the  chisel  penetrates  the  sigmoid  groove. 
A  fistulous  tract  may  be  found  leading  from  the  suppurating  mastoid 
cells  directly  into  the  groove  for  the  sigmoid  sinus  (Fig.  167),  or  the 
abscess  which  occupies  this  site  may  have  resulted  from  an  infection 
which  was  carried  from  the  mastoid  through  the  intercommunicating 


426 


THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


veins,  in  which  instance  no  communicating  sinus  will  be  found.  In 
either  case  the  vessel  wall  at  the  seat  of  the  abscess  is  usually  thickened 
and  seminecrotic  granulations  may  have  already  covered  the  most  ex- 
posed portion  of  the  dura.  Whatever  may  be  the  condition  in  which 
the  sinus  wall  is  found,  any  collection  of  pus  or  other  fluid  which  may 
be  present  should  be  dried  away  with  small  gauze  sponges,  after  which 
all  possible  information  concerning  the  sinus  contents  should  be  gained 
by  means  of  a  study  of  the  appearance  of  the  vessel  and  by  the  palpa- 
tion of  its  contents. 

If  the  sinus  is  normal  and  is  therefore  carrying  its  usual  amount  of 
venous  blood,  it  will  probably  present  a  dark  bluish  appearance.     In 


FIG.  270. — JANSEN'S  GOOSE-NECK  FORCEPS. 

case  it  is  completely  thrombosed,  and  there  should  be  in  addition  an 
inflammation  of  the  sinus  walls,  the  vessel  will  appear  darker  and  its 
walls  will  seem  unduly  thickened.  Should  the  contained  clot  be  in  a 
state  of  decomposition  the  walls  of  the  vessel  may  look  necrotic  and 
grayish.  On  palpation  the  vein,  if  normal,  will  feel  soft  and  usually 
some  pulsation  can  be  detected.  If  the  finger  be  placed  transversely 
across  the  sinus  at  the  lower  end  of  its  exposed  portion  and  sufficient 
pressure  be  exerted  on  it  to  occlude  its  lumen,  dilatation  will  take  place 
above  the  finger,  provided  the  vein  had  been  previously  patent.1 

1  It  was  formerly  thought  advisable  to  insert  a  hollow  exploring  needle  into  the  ex- 
posed sinus  and  to  make  the  attempt  to  aspirate  blood  from  the  vessel.  In  case  fluid  blood 
could  be  thus  aspirated  this  fact  was  regarded  as  sufficient  evidence  that  the  sinus  was 
not  thrombosed.  Absence  of  such  evidence  is  worthy  of  consideration  in  cases  where  the 
vessel  is  completely  filled  with  the  clot,  but  since  the  diagnosis  should  be  made  before  this 


INTRACRANIAL   COMPLICATIONS  427 

While  the  information  thus  obtained  is  of  some  value  it  should  not 
be  forgotten  that  it  is  impossible  by  such  means  alone  to  determine  with 
a  reliable  degree  of  certainty  whether  or  not  an  infected  clot  lies  within 
the  vessel.  The  importance  of  the  above  phenomena  as  a  means  of 
determining  the  existence  of  a  thrombus  was  emphasized  at  a  former 
time  when  other  and  more  reliable  diagnostic  aids  and  a  larger  expe- 
rience were  not  available  to  enable  the  operator  to  make  a  diagnosis  until 
a  late  period  of  the  disease,  and  not  until  after  the  vein  had  become  so 
completely  filled  with  the  clot  that  it  could  be  both  easily  seen  and  felt  by 
the  examiner.  At  the  present  time,  however,  the  diagnosis  should,  if 
possible,  be  made  long  before  such  visual  and  palpable  evidence  of 
thrombosis  is  present  in  the  vein;  and  therefore  at  this  early  stage,  when 
the  surgeon  is  given  opportunity  to  look  and  feel  for  evidence  of  disease 
within  the  sinus,  the  thrombus  is  yet  small,  and  in  fact  may  amount  to 
little  more  than  the  agglutination  of  a  trivial  amount  of  septic  material 
upon  the  site  of  the  invasion  of  the  vessel  wall  or  to  a  larger  but  soft  clot 
which  only  partially  fills  the  lumen.  In  either  case  the  blood  continues 
to  flow  through  the  vessel  in  a  more  or  less  normal  volume  and  the 
clot  cannot  be  felt  through  its  walls.  Furthermore,  the  thrombus  may 
not  be  located  in  the  sigmoid  sinus  at  all,  but  in  one  of  the  petrosal  veins; 
or,  that  which  is  more  commonly  the  case,  and  especially  in  children,  it 
may  have  occurred  primarily  in  the  jugular  bulb ;  in  which  latter  situation 
because  of  its  inaccessible  position  it  could  not  be  palpated.  Therefore 
unless  the  clot  is  large  enough  to  completely  block  the  vessel  the  latter 
may  appear  normal  in  every  respect,  may  feel  soft,  and  pulsation  may  be 
made  out.  Furthermore  pulsation  may  be  imparted  to  a  completely 
occluded  sinus  and  the  same  be  detected  by  the  examining  finger,  in 
case  there  is  an  active  inflammation  of  the  adjoining  cerebellar  structure. 

If  the  previous  history  of  the  case,  when  taken  in  connection  with 
the  evidence  acquired  by  the  examination  of  the  exposed  vein  as  just 
described,  is  not  sufficient  to  convince  the  surgeon  that  thrombosis  is 
present,  the  author  believes  that  the  wisest  course  to  pursue  would  be 
that  of  packing  the  mastoid  wound  at  this  juncture  and  awaiting  further 
development  in  the  case.  This  advice  would  seem  particularly  the 
proper  one  to  follow  in  cases  where  the  patient's  vital  powers  are  yet 
good,  and  in  whom,  therefore,  a  delay  of  further  operating  for  a  period 
of  from  twenty-four  to  forty-eight  hours  would  make  but  little  difference 
as  to  the  outcome,  but  might  add  much  to  the  certainty  of  a  diagnosis. 

time,  if  possible,  this  method  has  fallen  into  disuse.  Aspiration  is  not  free  from  danger 
since  several  operators  have  reported  infection  of  the  sinus  contents  as  a  result  of  the 
insertion  of  the  aspirating  needle. 


428  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

However,  if  the  previous  history  and  symptoms  of  the  patient  have  led 
to  the  very  conclusive  opinion  that  the  sinus  is  thromboscd  and  this  is  in 
sufficient  measure  confirmed  by  the  inspection  of  the  uncovered  vein, 
the  latter  should  at  once  be  opened  and  its  contents  inspected.  Before 
this  is  undertaken  the  entire  wound  and  all  instruments  should  be 
again  most  thoroughly  sterilized.  The  sinus  is  best  opened  by  means 
of  a  curved  and  pointed  bistoury,  the  entire  thickness  of  the  wall  being 
slit  for  a  distance  of  i  inch  or  more.  If  the  vessel  is  not  completely 
obstructed  by  the  thrombus  in  both  directions  a  free  hemorrhage  will 
follow.  Since  this  hemorrhage  may  be  so  profuse  as  to  at  once  obscure 
the  entire  operative  field  and  thus  greatly  hinder  the  progress  of  the 
operation,  some  provision  should  be  made  before  the  sinus  is  incised 
to  control  the  troublesome  bleeding  which  would  be  otherwise  certain 
unless  the  sinus  is  completely  occluded  by  a  blood-clot.  Two  small  but 
firm  rolls  of  sterile  gauze  should,  therefore,  be  prepared  and  placed 
across  the  sinus,  one  above  and  the  other  below  the  proposed  incision 
in  the  vessel;  the  management  of  these  should  be  intrusted  to  an 
assistant  whose  duty  it  shall  be  to  make  pressure  upon  each  at  the 
proper  moment.  The  assistant,  therefore,  places  the  forefinger  of  each 
hand  upon  the  respective  upper  and  lower  cylinders  of  gauze,  but  does 
not  exert  firm  pressure  upon  either  until  the  surgeon  has  freely  incised 
the  sinus  wall,  when,  should  a  free  hemorrhage  occur,  first  one  and  then 
the  other  roll  of  gauze  is  compressed  in  order  to  check  the  flow  of  blood 
and  to  determine  from  which  direction  it  comes.  If  the  lower  portion 
of  the  sinus  is  completely  thrombosed  while  the  upper  end  is  still  patent, 
the  bleeding  will  be  profuse  from  the  upper  end  only.  If  the  thrombus 
is  situated  below  the  entrance  of  the  inferior  petrosal  vein,  the  hemor- 
rhage will  be  free  from  both  directions;  that  from  the  direction  of  the 
bulb  coming  through  the  inferior  petrosal  vein.  If  the  mastoid  emissary 
vein  (Fig.  269)  is  large,  a  copious  flow  of  blood  may  take  place  from  this 
source  even  though  the  jugular  bulb  and  lower  portion  of  the  sigmoid 
sinus  be  completely  thrombosed.  Free  hemorrhage  from  the  torcular  end 
is  evidence  that  the  vein  in  this  direction  is  not  thrombosed,  and  hence 
curetment  in  this  direction  should  not  be  made.  When  any  clots  which 
may  be  present  in  any  part  of  the  sinus  have  been  thoroughly  removed 
by  the  curet  and  the  blood  is  observed  to  flow  normally  from  both  direc- 
tions, the  two  flaps  that  result  from  the  slit  in  the  sinus  wall  are  then 
folded  inward  into  the  lumen  of  the  sinus  and  pressed  against  the 
adjacent  tissues  by  means  of  a  little  roll  of  iodoform  gauze,  which  latter 
is  left  in  place  until  the  first  dressing.  This  procedure  is  sufficient  to 
check  all  hemorrhage,  after  which  the  mastoid  wound  is  filled  with 


INTRACRANIAL   COMPLICATIONS  429 

iodoform  gauze  strips  in  the  usual  way  and  the  operation  may  be  con- 
sidered finished. 

If  when  the  slit  is  made  into  the  sinus  it  is  found  that  the  vessel  is 
filled  with  a  thrombus  extending  in  both  directions,  no  bleeding  will,  as 
a  matter  of  course,  take  place,  and  it  will  be  necessary  to  empty  the  vein 
both  in  the  direction  of  the  torcular  and  toward  the  bulb.  But  before 
undertaking  this  an  important  and  often  difficult  question  must  be 
decided,  namely,  whether  or  not  the  jugular  vein  should  be  tied  in  the 
neck  before  attempting  to  remove  the  extensive  thrombus  from  the  sinus. 
This  question  must  be  settled  somewhat  according  to  the  previous 
symptoms  of  the  case,  but  largely  upon  the  condition  of  the  thrombosed 
vein  as  may  be  determined  at  the  moment  the  thrombus  is  exposed  by 
the  incision  through  the  walls  of  the  vessel.  If  the  symptoms  of  the 
case  have  been  severe,  if  the  cervical  glands  are  enlarged,  and  the  tissues 
of  the  neck  thickened,  these  general  indications  would  suggest  the  neces- 
sity of  ligation.  If  in  addition  to  the  above  information  the  thrombosis 
is  found  upon  opening  the  vein  to  be  extensive,  if  the  same  should  show 
signs  of  disintegration,  or  should  give  evidence  that  it  has  already  broken 
down  and  is  suppurating,  there  should  remain  no  question  concerning 
the  surgeon's  duty  to  ligate  the  jugular  and  perhaps  to  dissect  out  and 
remove  as  much  of  the  same  as  is  found  to  be  diseased  before  he  attempts 
to  curet  the  thrombus  from  the  sinus  above.  By  the  previous  ligation 
of  the  jugular  only  can  the  septic  thrombus  be  completely  removed,  for  the 
obvious  reason  that  curetment  of  the  sinus  cannot  be  effectively  per- 
formed through  the  incision  in  the  vessel  to  a  point  as  far  distant  as  the 
jugular  bulb  without  first  having  extensively  removed  the  bone  in  this 
direction;  and,  moreover,  even  if  it  were  possible  to  satisfactorily  cleanse 
the  vessel  by  means  of  this  procedure,  there  is  great  danger  of  dislodging 
particles  of  the  clot  into  the  general  circulation,  unless  this  has  been 
provided  against  by  the  previous  ligation  of  the  jugular.  It  is,  therefore, 
advisable  in  most  cases  of  complete  thrombosis  to  tie  off  the  jugular  as 
a  preliminary  step  to  the  removal  of  the  thrombus.  When  this  decision 
is  reached  the  mastoid  wound  should  be  temporarily  packed  with 
iodoform  gauze,  while  the  operator  proceeds  at  once  with  the  ligation 
of  the  jugular. 

Technic  of  the  Ligation  of  the  Internal  Jugular  Vein. — The 
antiseptic  dressings  that  were  applied  to  the  neck  on  the  previous  eve- 
ning or  at  the  time  the  patient  was  prepared  for  the  general  operation, 
are  now  removed,  while  the  hands  of  the  surgeon  and  assistants,  as  well 
as  all  instruments  to  be  further  used  in  the  completion  of  the  operation, 
are  thoroughly  sterilized.  A  sand-bag  is  placed  under  the  patient's  head 


43° 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


to  render  the  sternocleidomastoid  muscle  tense  and  to  place  the  deeper 
structures  in  the  most  favorable  position  for  the  operation.  The  vein 
in  the  upper  part  of  the  neck  runs  parallel  to  the  course  of  the  anterior 
margin  of  the  above-mentioned  muscle  (Fig.  271),  and  hence  the  latter 
is  used  as  a  landmark.  The  vessel  is  most  usually  ligated  below  the 
entrance  of  the  facial  vein,  and  hence  the  incision  into  the  neck  is  begun 
at  a  point  on  the  anterior  margin  of  the  muscle  horizontally  posterior  to 


Platysma 
Subcutaneous  fat 

Mylohyoid  muscle 
Digastric  muscle 


Facial  vein  i — 


Hypoglossal  nerve 

Lingual  vein 

Internal  carotid  artery 

Facial  artery 

Internal  jugular  vein 

Superior  laryngeal  nerve 

Vagus  nerve 

Thyroid  vein 

Longus  colli  muscle 

Internal  carotid  artery 

Sternohyoid  muscle 

Stcrnodeidomastoid  J 
muscle  | 

Trapezius  muscle 


Internal  jugular  vein 


Clavicle 


FIG.  271. — THE  INTERNAL  JUGULAR  VEIN  AND  ITS  SURGICAL  RELATIONS  IN  THE  TRIANGLES  OF  THE  XECK. 

the  angle  of  the  jaw  and  is  extended  downward  parallel  to  the  sterno- 
mastoid  for  i|  or  2  inches.  In  the  worst  cases  it  will  be  necessary  to 
carry  the  incision  to  the  clavicle.  The  skin  and  superficial  fascia  and 
the  platysma  myoides  muscle  are  divided  by  the  scalpel,  but  as  the 
deeper  structures  are  reached  the  dull  dissector  or  handle  of  the  scalpel 
should  be  substituted;  finally,  the  common  sheath  of  the  jugular,  carotid, 
and  pneumogastric  nerve  is  opened  upon  the  grooved  director  (Fig.  272). 


INTRACRANIAL    COMPLICATIONS 


431 


The  divided  superficial  vessels  are  all  immediately  clamped  and  perhaps 
ligated.  The  deeper  ones  are  pushed  aside  or  torn  across  by  the  blunt 
dissector,  but  should  they  bleed,  must  have  the  torsion  applied  at  once 
or  be  ligated,  because  it  is  entirely  essential  to  safe  operating  that  the 
entire  wound  be  dry,  so  that  the  operator  may  at  all  times  clearly  see 
the  structures  with  which  he  deals.  The  wround  is  meanwhile  held 
widely  open  by  means  of  two  retractors,  the  posterior  one  of  which  is 
hooked  deeply  under  the  sternocleidomastoid  muscle,  by  which  means 
the  latter  is  pulled  backward  and  well  away  from  the  common  sheath 
of  the  above-mentioned  vessels  and  nerve.  The  internal  jugular  vein 
lies  external  to  the  carotid  artery  and  pneumogastric  nerve  and  will, 
therefore,  come  into  view  first  when  the  common  sheath  of  the  vessels 


Platysma  myoides 
muscle 


Skin 


External  carotid 
artery 

Internal  carotid 
artery 

Phrenic  nerve-  — 


Pneumogastric 
nerve 


External  jugular 
vein 

Facial  vein 
Common  sheath 
Internal  jugular 
vein 

Sternocleidomastoid 
muscle 


FIG.  272. — SEGMENT  OF  CROSS-SECTION  OF  THE  XECK  IN  THE  UPPER  CERVICAL  TRIANGLE,  SHOWING  THE 
DEPTH  AND  RELATION  OF  THE  INTERNAL  JUGULAR  VEIN. 

is  opened.  The  vein  may  be  recognized  by  its  dark  blue  color  unless 
there  has  been  present  a  cellulitis  with  resulting  inflammatory  exudate, 
which  has  obliterated,  to  a  great  extent,  the  normal  appearance.  Lying 
as  it  does  upon  the  carotid  artery,  the  throbbing  impulse  of  the  latter 
is  imparted  to  the  vein,  even  when  the  latter  is  thrombosed;  and  for 
this  reason  pulsation  in  the  vessel  is  not  an  indication  that  it  is  un- 
obstructed by  a  thrombus,  but  if  patent  to  the  blood-current  the 
respiratory  effect  upon  the  vessel  will  always  be  evident  to  the  ob- 
server. The  vein  is  elevated  from  the  nerve  and  artery  by  sepa- 
rating the  cellular  tissues  in  which  all  are  imbedded  by  means  of 
a  slightly  curved  dull  dissector,  the  greatest  care  being  always  taken  that 
no  injury  be  done  to  the  other  structures  which  lie  within  the  common 


432  THE    PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 

sheath.  In  cases  where  the  vein  has  been  completely  occluded  by  the 
thrombus,  either  in  the  sigmoid  sinus  or  jugular  bulb,  that  portion  in  the 
neck  will  probably  be  collapsed  and,  therefore,  much  more  difficult  to 
find  than  if  it  were  either  normal  or  filled  with  a  coagulum.  A  double 
catgut  ligature  is  passed  around  the  vessel  below  the  entrance  of  the 
facial  vein,  or  still  lower  if  the  clot  extends  further  down  the  vessel,  by 
means  of  an  aneurysm  needle,  and  the  jugular  is  tied  in  two  places  i 
inch  apart.  The  surgeon  must  never  fail  to  lift  the  vein  up  and  inspect 
its  whole  circumference  carefully  in  order  to  be  sure  that  nothing  but  the 
vein  itself  is  included  in  either  ligature.  Negligence  concerning  this 
precaution  might  result  in  tying  the  pneumogastric  nerve  together  with 
the  vein.  Following  the  double  ligation  the  intervening  portion  of  the 
vessel  is  completely  severed  by  a  straight  scissors. 

Subsequent  to  the  ligation  and  severance  of  the  vein  in  the  neck, 
equally  experienced  operators  differ  as  to  the  disposition  that  should 
be  made  of  that  portion  which  lies  between  the  upper  ligature  and  the 
jugular  bulb,  one  class  believing  that  it  is  best  to  tie  off  all  the  inter- 
vening contributory  veins  and  then  to  dissect  out  the  trunk  of  the  vessel 
as  high  toward  the  jugular  bulb  as  possible,  again  ligate  at  the  upper 
limit  of  the  dissection,  and  then  to  sever  and  remove  this  portion  of  the 
internal  jugular  entirely  from  the  neck.  The  other  class  maintains 
that  equally  good  results  are  usually  obtained  if  only  the  circulation  of 
the  infected  part  is  cut  off  from  the  general  system  by  means  of  the 
simple  ligation  and  division  of  the  vein.  If  the  thrombosed  contents 
of  the  vein  are  infected  and  breaking  down  of  the  clot  with  suppuration 
is  likely  to  result  in  any  case,  undoubtedly  good  surgery  requires  that 
much  of  the  vein,  together  with  its  contents,  be  gotten  rid  of  as  soon  as 
possible,  and  hence  the  plan  of  dissecting  the  vessel  out  of  the  neck 
should  be  followed.  On  the  contrary,  if  the  condition  of  the  vessel  at 
the  time  of  operation  indicates  that  the  lower  end  of  the  thrombus  is 
not  infected  and  wrill  therefore  not  likely  disintegrate  or  give  rise  to 
local  or  general  infection — and  this  is  more  probable  in  the  cases  whch 
are  operated  on  early — then  the  vessel  may  be  safely  left  in  situ  after  once 
it  is  ligated  and  divided.  When  the  deep  cervical  glands  have  become 
infected  and  consequently  enlarged,  they  will  be  easily  distinguished 
during  this  operation,  and  should  be  removed  in  order  to  avoid  sub- 
sequent infection  from  this  source. 

Ballance,  of  London,  advises  that  the  upper  end  of  the  vein  be 
brought  out  through  the  wound  and  used  as  a  drainage-tube.  This 
disposition  of  it  would  seem  decidedly  proper  in  cases  where  suppura- 
tion had  already  taken  place  or  was  imminent.  When  the  plan  of 


INTRACRANIAL   COMPLICATIONS  433 

resection  of  the  jugular  is  chosen  it  will  be  found  necessary  to  ligate 
all  the  large  tributary  veins  before  these  are  severed  from  the  main 
trunk.  In  case  the  thrombus  extends  down  the  jugular  for  a  consider- 
able distance  it  may  be  found  that  several  of  the  entering  veins  are 
themselves  thrombosed.  When  this  is  the  case  the  ligatures  should  be 
applied  to  these  vessels,  and  the  same  should  be  divided  and  removed 
beyond  the  occluded  portion  when  possible. 

Whether  a  portion  of  the  vein  is  or  is  not  removed  from  the  neck 
after  ligation,  the  cervical  wound  should  be  freely  flushed  with  normal 
saline  solution  and  a  gauze  wick  or  cigarette  drain  inserted  from  the 
upper  to  the  lower  end.  Deep  sutures  are  then  introduced  and  the 
whole  incision  is  closed  over  the  drain  with  the  exception  of  a  small 
opening  at  each  end  for  the  entrance  and  exit  of  the  drain.  In  case 
the  cellular  structures  of  the  neck  are  infected  and  perhaps  suppurating 
no  sutures  should  be  introduced,  and  the  whole  cervical  wound  should 
be  packed  with  iodoform  gauze  until  healing  by  granulation  has  been 
completed.  The  chief  avenue  through  which  septic  material  can  enter 
the  system  having  now  been  closed  by  the  ligation  or  removal  of  the 
internal  jugular,  the  final  step  of  the  operation — namely,  the  removal  of 
the  thrombus  from  the  sigmoid  sinus — should  be  undertaken.  The 
operator,  therefore,  removes  the  gauze  from  the  mastoid  wound,  exposes 
the  sinus,  and  proceeds  to  curet  the  clots  away.  It  is  better  to  empty 
the  vessel  in  the  direction  of  the  bulb  first  for  the  reason  that  if  the 
inferior  petrosal  sinus  is  implicated  no  hemorrhage  will  occur  from 
below,  and  the  work  of  the  removal  can,  therefore,  be  more  easily 
performed;  and  should  the  petrosal  be  patent  and  free  bleeding  occur, 
no  advantage  is  lost  by  beginning  on  the  lower  portion  first.  A  curet 
of  proper  size  and  curvature  is,  therefore,  inserted  into  the  sinus  in  the 
direction  of  the  bulb  and  the  infected  contents  of  the  vessel  are  thereby 
removed.  It  may  be  necessary  to  reinsert  the  instrument  several 
times  before  all  of  the  clot  can  be  withdrawn.  If  the  sinus  walls  have 
been  infected  for  several  days  it  is  possible  that  softening  of  their  struc- 
ture has  taken  place,  and,  therefore,  the  curetment  must  be  gently 
performed,  since  otherwise  the  instrument  would  penetrate  into  the 
cerebellar  fossa  and  result  in  rapid  spread  of  the  infection  with  almost 
certainly  fatal  consequences.  If  after  the  thrombosed  vein  has  been 
emptied  by  the  curetment  no  bleeding  occurs  from  the  direction  of 
the  jugular  bulb,  it  may  be  safely  inferred  that  the  inferior  petrosal 
vein  is  implicated;  and,  therefore,  if  the  condition  of  the  patient  will 
permit  of  further  operating,  the  bone  should  be  removed  from  the  sinus 
in  this  direction  as  far  as  the  jugular  fossa  if  necessary.  This  will 

28 


434 


THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


enable  the  operator  to  empty  the  bulb  of  any  remaining  clots,  and 
possibly  to  expose  the  mouth  of  the  petrosal  vein  to  an  extent  that  a 
flow  of  blood  from  this  direction  may  be  secured.  Should  portions  of 
the  infected  thrombus  be  left  in  the  sinus  subsequent  danger  of  general 
infection  may  arise,  although  this  is  greatly  lessened  by  the  previous 
ligation  of  the  jugular. 


Temporal  muscle 
Periosteum 

Linea  temporalis 
Fibrocartilaginous  canal 
Tympanomastoid  duct 

Sigmoid  sinus 

Jugular  bulb 
Facial  nerve 
Glossopharyngeal  nerve 
Sternocleidomastoid  muscle 
Spinal  accessory  nerve 
External  jugular  vein 
Hypoglossaf  nerve 
Vagus  nerve 
Digastric  muscle 
Internal  carotid  artery 
External  jugular  vein 
Areolar  tissue 
Ascending  cervical  artery 

Scalenus  anticus  muscle 
Facial  vein 

Hypoglossal  nerve 
Internal  jugular  vein 
External  carotid  artery 
Desc.  branch  of  hypoglossus 
Vagus  nerve 
Sternocleidomastoid  muscle 


Fie.  273. — DISSECTION  or  THE  MASTOID  AND  CERVICAL  REGION  SHOWING  ALL  THE  STRUCTURES  WITH 
WHICH  THE  OPERATOR  MUST  DEAL  IN  PERFORMING  THE  SEVERAL  OPERATIONS  CONNECTED  WITH  THE  SURGERY 
OF  THE  EAR. 

In  duplicating  this  dissection  on  the  cadaver  the  student  will  better  comprehend  the  many  difficulties  with 
which  the  operator  may  meet  in  executing  the  necessary  steps  of  these  operations. 

The  upper  or  torcular  end  of  the  sigmoid  sinus  should  next  receive 
attention,  and  is  emptied  of  its  clots  by  inserting  the  curet  backward 
and  then  gently  withdrawing  the  instrument  along  first  one  wall  of  the 
sinus  and  then  another  until  the  whole  has  been  cleansed  from  any 
obstruction.  When  the  sinus  is  reopened  this  fact  may  be  known  by 


INTRACRANIAL   COMPLICATIONS  435 

the  free  flow  of  blood  which  immediately  occurs  from  the  torcular  end. 
If  it  is  found  impossible  to  remove  all  the  obstruction  and  to  establish  the 
blood-current  by  working  through  the  osseous  opening  that  was  earlier 
provided,  the  bone  should  be  removed  for  any  necessary  distance  over 
the  backward  course  of  the  sinus,  and  the  cureting  be  then  continued 
until  the  blood  flows  in  an  unobstructed  stream.  When  this  has  been 
accomplished  the  edges  of  the  sinus  walls  are  folded  together  as  above 
described,  and  the  sinus  itself  is  pressed  against  the  adjacent  structures 
by  means  of  a  properly  shaped  compress  of  iodoform  gauze.  The 
mastoid  wound  is  dressed  by  means  of  a  separate  gauze  packing,  the 
same  methods  being  followed  as  have  heretofore  been  described.  The 
surgical  relation  of  all  the  structures  with  which  the  surgeon  must  deal 
in  performing  the  several  operations  for  the  relief  of  sinus  thrombosis 
is  very  excellently  shown  in  the  dissection  represented  in  Fig.  272. 

The  first  dressing  is  allowed  to  remain  forty-eight  hours  and  often 
longer,  depending  altogether  upon  the  subsequent  symptoms  of  the 
patient.  When  the  jugular  has  been  ligated  in  the  neck  the  dressing 
of  this  portion  of  the  wound  will  usually  require  attention  at  the  same 
time.  In  case  the  vein  has  been  dissected  out  of  the  neck  and  a  cigarette 
or  gauze  drain  has  been  inserted  the  whole  length  of  the  cervical  wound, 
i  inch  or  more  of  this  gauze  should  be  pulled  from  the  lower  angle  and 
the  extracted  portion  cut  off  at  this  and  each  subsequent  dressing 
until  the  drain  is  wholly  removed.  At  the  first  dressing  the  sigmoid 
sinus  may  be  found  collapsed  and  its  inner  walls  adherent;  it  may  be 
suppurating  or  granulations  may  be  found  already  springing  up  which 
will  in  time  obliterate  its  lumen.  If  suppuration  occurs  a  free  outlet 
must  be  provided  for  the  pus  and  its  rapid  absorption  secured  by  means 
of  frequent  dressings  and  the  liberal  use  of  iodoform  gauze.  Unless 
the  vein  has  been  brought  out  of  the  upper  end  of  the  wound  after  it 
has  been  ligated,  according  to  the  method  of  Ballance,  and  is  used  as  a 
drainage-tube,  it  would  be  unsafe  to  employ  irrigation  as  a  means  of 
cleansing,  for  the  reason  that  by  so  doing  there  is  danger  of  washing 
septic  matter  into  the  general  circulation  through  anastomosing  vessels 
(see  Fig.  268). 


CHAPTER  XXXIV 
INTRACRANIAL   COMPLICATIONS    (Continued) 

OTITIC    BRAIN   ABSCESS.— PATHOLOGY,  SYMPTOMS,  DIAGNOSIS, 

AND  PROGNOSIS 

Pathology. — Of  all  brain  abscesses  those  of  otitic  origin  are  the 
most  common.  In  the  first  years  of  life  cerebral  and  especially  cere- 
bellar  abscesses  are  much  rarer  than  in  adults.  Abscess  is  most  common 
in  the  second  and  third  decennial,  according  to  Bezold.  However,  every 
brain  abscess  in  the  presence  of  disease  of  the  temporal  bone  is  not 
necessarily  thus  originated.  The  abscess  may  be  situated  far  from  the 
focus  of  suppuration  in  the  temporal  bone  and  even  on  the  opposite 
half  of  the  brain.  Infection  may  be  carried  by  pyemic  metastases  from 
the  lungs  or  from  putrid  processes  in  other  organs,  as,  for  example, 
empyema  of  the  pleura,  endocarditis,  osteomyelitis,  or  tubercular  dis- 
ease. Extension  of  suppuration  may  occur  either  from  the  labyrinth 
or  sigmoid  sinus,  and  rarely  from  the  hiatus  subarcuatus,  according  to 
Hinsburg.  Korner  states  that  otitic  brain  abscess  is  situated  in  the 
immediate  neighborhood  of  the  primary  seat  of  the  disease  in  the 
temporal  bone.  Accepting  this  rule,  the  collection  of  pus  must  be  in 
the  temporal  lobe  of  the  cerebrum  or  in  the  cerebellum.  This  class  of 
abscess  is  usually  single,  whereas  abscesses  not  of  otitic  origin  are  often 
multiple.  The  primary  suppuration  in  the  temporal  bone  is  more  often 
chronic  than  acute  and,  as  a  rule,  is  preceded  by  extensive  disease  of 
the  bone,  as  caries,  necrosis,  and  erosions  by  cholesteatomata.  Ham- 
merschlag  states  that  about  25  per  cent,  of  brain  abscesses  occur  after 
acute  middle-ear  suppuration.  Otitic  abscesses  in  the  temporal  lobe 
are  twice  as  frequent  as  those  in  the  cerebellum,  according  to  Korner. 
Suppuration  can  progress  directly  or  indirectly  from  the  original  focus 
to  the  brain.  Eulenstein  says  that  direct  progression  is  rare,  in  which 
case  the  purulent  inflammatory  process  attacks  the  bone  and  passes  by 
continuity  to  the  dura;  the  dura  agglutinates  with  the  pia  and  surface 
of  the  brain  and  suppurative  softening  of  the  latter  takes  place.  As 
a  rule  a  thin  layer  of  brain  substance  lies  between  the  abscess  and 
the  brain  membranes  (see  Fig.  273).  In  the  indirect  progression  of 
the  disease  from  the  infected  foci  in  the  temporal  to  cranial  cavity, 

436 


INTRACRANIAL    COMPLICATIONS  437 

bacteria  gain  entrance  from  the  primary  focus  by  way  of  the  lymph- 
atics, the  sheaths  of  arteries,  the  perforating  veins,  or  along  the 
nerve-sheaths  of  the  facial  or  auditory  nerves.  The  infection  may 
follow  the  blood  paths,  as  Korner  suggests,  by  extension  of  throm- 
bosis and  phlebitis  in  the  pial  vessels.  In  this  indirect  way  the  tissue 
between  the  brain  abscess  and  the  dura  does  not  show  any  macroscopic 
changes.  After  the  bacteria  have  gained  an  entrance  either  red  or 
white  softening  may  take  place,  according  to  whether  there  is  much 
hemorrhagic  extravasation  or  little;  the  brain  tissue  disintegrates  with 
the  formation  of  pus,  and  then,  if  the  surrounding  brain  substance 


Interior 
abscess  cav 


Thick  fibre 
retention  w 


FIG.  274. — CASE  OF  LARGE  CHRONIC  TEMPOROSPHENOIDAI,  BRATN  ABSCESS  WITH  THICK  FIBRINOUS  RETEN- 
TION WALLS. 

possesses  sufficient  vitality,  fibrin  and  leukocytes  are  thrown  out  which 
form  a  capsule  around  the  collection  of  pus.  The  thickness  of  the 
abscess  capsule  varies  from  i  to  5  mm.  or  more  (Fig.  274).  The  capsule 
may  become  calcified,  vessels  may  penetrate  it  from  the  brain  tissue,  and 
the  abscess  may  be  absorbed ;  or  the  capsule  may  be  replaced  by  granula- 
tion tissue  with  increased  formation  of  pus,  the  pressure  from  which  may 
thin  the  capsule  and  cause  rupture  of  the  abscess  into  the  ventricles  of 
the  brain  or  into  the  subdural  space. 

Symptoms. — The  symptoms  of  acute  and  chronic  brain  abscess 
differ  greatly  in  violence.     In  the  acute  variety  all  the  symptoms  are 


438  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

usually  more  pronounced  in  the  beginning  and  grow  more  rapidly 
worse  than  is  the  case  in  the  chronic  form  of  the  affection.  When 
brain  abscess  is  chronic  the  pus  may  become  encysted  and  the  symp- 
toms of  the  disease  remain  vague  and  indefinite  throughout  a  period 
of  many  months  or  even  years.  The  most  prominent  symptoms  of 
both  acute  and  chronic  abscess  of  the  brain  are  pain,  vomiting,  slow 
pulse,  normal  or  subnormal  temperature,  rigors,  intra-ocular  changes, 
cessation  of  the  aural  discharge,  slow  cerebration,  and  perhaps  paralysis 
of  certain  groups  of  muscles.  All  of  these  symptoms  are  seldom  present 
at  one  time  or  in  any  one  case,  but  if  careful  note  be  made  of  the  entire 
progress  of  the  abscess,  many  and  perhaps  the  majority  of  those  above 
noted  may  be  observed  in  a  large  percentage  of  cases. 

The  pain  in  the  beginning  may  occur  only  in  the  depths  of  the  ear 
of  the  affected  side,  from  which  point  it  later  radiates  over  the  temporal 
and  mastoid  regions,  and  finally  concentrates  upon  some  small  area 
which  may  be  located  at  quite  a  distance  from  the  affected  ear.  The 
pain  during  the  early  stage  of  the  abscess  formation  is  partly  the  result 
of  faulty  drainage,  and  should  the  pus  by  its  own  pressure  break  into 
some  new  and  larger  channel,  temporary  relief  may  at  once  occur. 
In  cases  of  chronic  brain  abscess  the  pain  may  intermit  for  several 
hours  or  even  days,  only  to  return  with  its  former  severity.  During  such 
intervals  of  freedom  from  suffering  the  patient  believes  great  improve- 
ment has  taken  place,  and  he  may  resume  his  occupation  until  such 
time  as  he  is  again  compelled,  on  account  of  his  suffering,  to  abandon 
his  task  and  remain  indoors  or  even  in  bed.  The  author  has  observed 
two  cases  through  long  periods  in  which  this  pain  recurred  at  irregular 
intervals  of  from  one  to  several  hours.  Both  would  industriously  read 
any  convenient  book  with  seeming  interest  and  pleasure  or  would 
engage  in  games  enthusiastically  and  successfully;  would  laugh  and  talk 
as  vigorously  as  though  they  enjoyed  life  to  its  fullest  extent,  until 
suddenly,  when  seized  with  the  pain  over  the  temporal  region,  they 
would  abruptly  cease  what  they  were  doing,  hold  the  head  between  the 
hands,  and  would  cry  out  in  great  agony.  At  a  later  period  in  the 
disease  the  pain  became  constant  though  less  severe,  and  frequent 
attacks  of  screaming  occurred  in  one  case  for  a  few  days  preceding  the 
fatal  termination. 

Vomiting  is  a  symptom  which  occurs  in  nearly  all  intracranial 
diseases  in  which  inflammation  is  present  or  where  there  is  pressure 
from  fluids  or  tumors  upon  the  cerebral  or  cerebellar  structures.  While, 
therefore,  vomiting  occurs  in  many  cases  as  a  symptom  of  brain  abscess 
at  some  period  during  the  progress  of  the  disease,  this  symptom  is 


INTRACRANIAL   COMPLICATIONS  439 

helpful  in  a  diagnostic  way  only  when  taken  in  connection  with  other 
and  more  important  ones. 

The  course  of  the  temperature  has  a  much  greater  significance. 
In  the  beginning  of  the  brain  abscess,  when  there  is  likely  to  be  present 
a  complicating  localized  meningitis,  the  temperature  is  elevated,  but 
not  high,  and  seldom  exceeds  101°  F.  It  is  likewise  elevated  toward 
the  close  of  the  disease  should  the  latter  end  fatally,  since  usually  a 
leptomeningitis  or  cerebritis  is  added  at  this  stage.  In  the  intermediate 
period,  however,  when  the  abscess  has  developed  to  a  sufficient  size  to 
produce  pressure  upon  the  adjacent  brain  structure,  the  temperature 
is  often  normal  or  subnormal,  and  in  some  instances  falls  as  low  as  97° 
F.,  at  which  point  it  may  persist  for  several  days.  This  behavior  of  the 
temperature  is  strikingly  different  from  that  of  either  sigmoid  sinus, 
thrombosis,  or  meningitis,  and  when  accompanied  by  other  symptoms 
of  brain  complication  is  most  significant  of  brain  abscess. 

The  pulse  rate  is  of  equal  diagnostic  importance  to  the  low  tempera- 
ture, and  in  uncomplicated  cases  it  bears  a  close  relationship  to  the  latter. 
Thus,  in  the  early  stages,  when  a  localized  meningitis  of  sufficient  extent 
exists  over  the  abscess  cavity  to  produce  a  rise  in  temperature,  the 
pulse  is  also  somewhat  quicker  than  normal;  but  as  the  size  of  the  abscess 
increases  to  the  extent  of  producing  considerable  pressure  in  the  portion 
of  the  brain  which  it  occupies,  the  pulse-rate  is  reduced  and  may  be  as 
low  as  40  per  minute,  although  the  average  rate  is  between  60  and  70. 
Both  the  slow  pulse  and  lowered  temperature  are  attributable  to  the 
pressure  exerted  upon  the  brain  structures  by  the  accumulated  fluid, 
and,  therefore,  small  abscesses  may  produce  but  little  change  in  this 
respect,  while  the  same  is  true  of  a  large  chronic  abscess  that  has  become 
encapsulated,  and  consequently  is  separated  from  healthy  brain  tissue 
by  a  thick  protecting  wall  of  fibrous  or  connective  tissue,  and  will,  there- 
fore, be  incapable  of  creating  a  pressure  upon  its  environment  to  a 
degree  that  will  affect  either  the  pulse  or  temperature. 

When  the  pulse  is  slow  because  of  an  intracranial  pressure  it  is 
usually  also  full  and  strong,  but  should  the  disease  approach  a  fatal 
termination  the  heart's  action  becomes  both  rapid  and  weaker.  Gen- 
eral meningitis  sometimes  complicates  a  brain  abscess,  and  when  this  is 
the  case  a  rather  curious  phenomena  may  arise,  in  so  much  as  the  pulse 
remains  abnormally  slow,  whereas  the  temperature  is  high.  Should 
the  abscess  rupture  into  the  ventricles  or  break  upon  the  surface  of  the 
brain,  the  pulse  will  almost  immediately  become  weaker  and  faster  and 
the  temperature  will  rapidly  rise. 

Chills  are  not  of  as  frequent  occurrence  in  this  disease  as  in  sinus 


44°  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

thrombosis,  and  when  they  do  take  place  are  usually  not  so  severe,  and 
are  not  followed  by  profuse  and  exhaustive  sweats.  A  brain  abscess 
may  run  its  whole  course  to  a  fatal  termination  without  a  single  chill  or 
.even  chilly  sensation  having  been  complained  of.  On  the  other  hand, 
a  rigor  will  almost  certainly  occur  when  the  abscess  makes  each 
advance.  Thus,  should  a  rupture  of  an  abscess  take  place  in  any 
direction,  the  occurrence  will  in  all  probability  be  marked  by  a  chill  of 
some  degree  of  severity.  The  establishment  of  a  secondary  abscess 
or  of  a  general  meningitis  of  either  variety  will  likewise  be  announced 
by  a  rigor. 

The  general  appearance  of  the  patient  while  not  in  any  sense  char- 
acteristic, is  often  indicative  of  the  presence  of  a  severe  illness.  The 
face  may  be  sallow  and  worn,  the  body  emaciated,  and  every  feature  be 
one  such  as  to  impress  the  observer  that  the  individual  has  undergone 
much  suffering.  Macewen  has  called  attention  to  the  presence,  when 
the  abscess  is  fully  established,  of  a  putrid  odor  to  the  breath,  and  states 
that  the  odor  persists  even  after  the  suppurating  ear  and  the  foul  tongue 
and  mouth  of  the  patient  have  been  thoroughly  cleansed.  The  author 
has  seen  one  case  of  brain  abscess  in  which  this  odor  was  markedly 
present.  The  hair  of  the  scalp  sometimes  seems  lifeless  over  the  affected 
side  of  the  head,  and  the  scalp  itself  is  wrinkled  and  has  a  tendency  to 
become  scurfy  over  the  diseased  area. 

Ocular  symptoms  in  the  form  of  photophobia,  inequality  of  pupils, 
diplopia,  or  optic  neuritis  are  present  at  some  stage  of  the  abscess  in 
a  large  proportion  of  all  cases.  Photophobia  is  most  often  seen  in  the 
first  few  days  of  the  abscess,  whereas  the  other  eye  symptoms  above 
enumerated  develop  as  the  abscess  enlarges  and  sets  up  inflammation 
or  pressure  on  adjoining  structures.  Optic  neuritis  may  be  present  in 
both  eyes,  but  not  with  the  same  intensity  in  each.  Vision  is  not  seriously 
affected  by  the  occurrence  of  this  affection,  and  does  not  occur  at  all  if 
the  abscess  is  only  of  short  duration  or  if  it  is  small.  This  particular  eye 
complication  may  be  the  result  of  other  intracranial  diseases — namely, 
tumor  of  the  brain,  meningitis,  and  cerebritis — and  its  presence  cannot, 
therefore,  be  considered  as  highly  diagnostic  of  brain  abscess  except 
when  with  it  are  associated  such  other  important  symptoms  as  a  dis- 
charging ear,  localized  pain,  vomiting,  a  slow  pulse,  and  a  normal  or 
subnormal  temperature.  The  pupils  are  not  usually  affected  when  the 
abscess  is  small,  but  when  large  and  located  in  the  temporosphenoidal 
lobe  the  pupil  of  the  eye  on  the  same  side  may  be  greatly  dilated  and 
fixed.  When  only  moderately  dilated  it  may  be  found  that  the  pupil  of 
the  affected  side  will  react  to  light  with  such  sluggishness  when  compared 


INTRACRANIAL   COMPLICATIONS  44! 

with  the  behavior  of  its  fellow  in  this  respect  as  to  furnish  a  valuable 
symptom. 

Another  symptom  which  is  sometimes  observed  is  the  cessation  of 
the  aural  discharge  at  a  time  coincident  with  the  development  of  symp- 
toms of  the  intracranial  disease.  When  cessation  of  the  discharge  thus 
suddenly  occurs  it  is  most  likely  a  result  of  the  pus  having  broken  into 
some  new  and  larger  channel,  as,  for  instance,  into  the  cranium,  and  not 
to  a  sudden  lessening  in  the  quantity  of  the  formation  of  the  pus.  Ces- 
sation of  the  aural  discharge  may  be  a  symptom  of  meningitis  or  sinus 
thrombosis  as  well  as  of  the  disease  under  consideration. 

When  a  brain  abscess  develops  somewhat  rapidly  and  attains  a  size 
sufficient  to  produce  considerable  pressure  upon  the  surrounding  struc- 
ture, the  patient's  mentality  may  become  impaired  and  cerebration  may 
be  exceedingly  slow.  In  this  respect  this  symptom  of  brain  abscess  is 
similar  to  the  later  stages  of  typhoid  fever,  since  in  either  disease  if  the 
individual  is  asked  a  question  he  will  hesitate  a  very  long  time  before 
giving  even  the  briefest  answer;  or  if  requested  to  protrude  the  tongue  or 
close  the  eyes  he  will  delay  several  seconds  before  heeding,  although  his 
final  compliance  furnishes  certain  evidence  that  he  understood  perfectly 
from  the  first.  Drowsiness  also  accompanies  this  mental  state,  and  the 
patient  is  apparently  always  asleep  and  must  be  aroused  on  every 
occasion  when  food  or  medicines  are  administered.  In  the  advanced 
stages  of  the  disease  the  patient  may  fall  asleep  again  after  he  is  awakened 
and  before  he  can  find  words  to  answer  a  question  or  before  he  has 
swallowed  the  proffered  food  or  drugs.  When  not  interfered  with  sur- 
gically this  stupor  gradually  deepens  into  coma  and  death;  or  if  the 
abscess  ruptures  into  the  ventricles  the  death  may  occur  more  suddenly. 

Paralysis,  either  partial  or  complete,  may  occur  as  the  result  of  a 
destruction  by  the  abscess  of  all  or  some  portion  of  a  given  motor  area; 
or  the  palsy  may  result  from  the  pressure  of  the  abscess ;  or  to  the  accom- 
panying zone  of  inflammation  surrounding  it.  Extensive  paralysis  is 
not  common,  since  it  is  observed  only  in  cases  where  the  abscess  is  very 
large  or  when  it  is  located  in  the  motor  area  (see  Fig.  269).  The 
external  rectus  muscle  is  sometimes  paralyzed,  in  which  case  the  affected 
eye  looks  inward,  producing  the  conditions  of  a  convergent  squint.  In 
its  worst  forms  the  paralysis  may  affect  the  opposite  arm  and  leg,  as  was 
observed  by  the  author  in  one  case  in  which  a  large  temporosphenoidal 
abscess  was  accompanied  by  a  complete  paralysis  of  the  opposite  arm 
and  a  paresis  of  the  opposite  leg. 

An  irritable  disposition  of  the  individual  has  also  been  noted  as  an 
early  symptom,  but  little  is  usually  thought  of  it  until  graver  conditions 


442  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

have  fully  developed.  As  an  early  symptom  and  especially  when  taken 
in  connection  with  those  already  given,  it  has  some  diagnostic  value. 

Diagnosis. — The  positive  determination  of  the  presence  of  a  brain 
abscess  is  in  most  instances  impossible  in  the  earlier  stages,  and  is  nearly 
always  difficult  at  any  period  of  the  disease.  The  latent  or  chronic 
cases  of  encysted  abscess  may  remain  symptomless  for  months  or  even 
years,  and  the  actual  condition  within  the  brain  during  all  this  time  may 
never  be  suspected  by  any  one.  The  author  has  seen  one  such  case 
in  which  a  boy  ten  years  old  attended  school  regularly  up  to  within 
a  few  weeks  of  his  death,  and  was  undoubtedly  a  student  of  more  than 
average  ability;  nevertheless  the  autopsy  showed  a  temporosphenoidal 
abscess  of  large  proportion,  the  capsule  of  which  was  so  thick  that  it 
must  have  been  many  months,  if  not  years,  in  forming  (see  Fig.  274). 
On  the  other  hand,  an  acute  brain  abscess  of  large  dimensions  may  take 
place  within  the  short  period  of  two  weeks,  during  ah1  of  which  time 
symptoms  of  some  grave  affection  of  the  head  are  constantly  manifest. 

In  addition  to  the  symptoms  already  given,  the  diagnosis  must  be 
made  largely  upon  the  physical  examination  of  the  ear  itself.  A  dis- 
charging ear  nearly  always  precedes  and  accompanies  a  brain  abscess, 
except  when  of  traumatic  origin.  The  fact  that  the  patient  or  his 
friends  may  deny  the  presence  of  an  aural  discharge  should  not  deter  the 
diagnostician  from  making  the  most  exacting  examination  of  the  con- 
dition of  the  fundus  of  the  ear,  and  of  ascertaining  to  an  exact  certainty 
the  precise  state  of  the  middle  ear  and  its  connecting  air  spaces.  Every 
means  of  examination  known  to  otology  that  will  aid  in  the  accuracy  of 
this  examination  should  be  used,  to  the  end  that  the  information  thus 
gained  is  positive,  and,  therefore,  of  definite  value  when  taken  in  con- 
nection with  symptoms  which  are  already  present  in  the  case  or  may 
shortly  develop.  While  there  is  not  likely  to  be  found  present  in  the  ear 
any  condition  that  is  pathognomonic  of  brain  abscess,  nevertheless,  if 
granulations,  polypi,  carious  bone,  or  cholesteatoma  be  found  in  or  ad- 
jacent to  the  middle  ear  in  a  patient  who  has  symptoms  of  an  intracranial 
disease,  this  fact  would  have  great  weight  in  the  final  decision  as  to  the 
character  of  the  ailment. 

Since  a  mastoiditis  is  also  nearly  always  included  in  the  pathologic 
chain  that  ultimately  leads  to  the  intracranial  disease,  the  symptoms 
of  this  affection  may  simulate  or  even  completely  mask  those  which 
arise  from  the  brain  abscess.  The  diagnosis  in  such  cases  cannot  be 
certainly  made  out  until  the  mastoid  has  been  opened  and  its  connecting 
cavities  are  freed  from  their  diseased  foci.  If  the  previously  existing 
intracranial  symptoms  are  not  relieved  by  the  mastoid  operation,  and 


INTRACRANIAL   COMPLICATIONS  443 

if  the  presence  of  concomitant  general  disease  can  be  eliminated  from 
the  case,  then  an  exploration  of  the  cranial  cavity  for  diagnostic  purposes 
is  a  perfectly  justifiable  measure  and  should  be  undertaken.  Par- 
ticularly is  an  exploration  in  the  vicinity  of  the  mastoid  and  middle  ear 
indicated  if  the  symptoms  all  point  to  a  local  disease  and  the  patient 
shows  evidence  of  doing  badly  under  other  treatment. 

Finally,  when  in  the  course  of  an  aural  suppuration  symptoms 
develop  which  lead  to  the  suspicion  of  an  intracranial  involvement,  it 
becomes  necessary,  in  order  to  make  an  early  and  correct  diagnosis, 
to  place  the  patient  under  frequent  observation  and  to  make  a  com- 
plete record  of  every  feature  of  the  progress  of  the  disease,  embracing 
especially  a  record  of  the  pulse,  temperature,  the  presence  or  absence 
of  rigors,  vomiting,  and  all  other  symptoms  likely  to  arise  during  this 
complication.  Such  a  record,  when  carefully  and  competently  made, 
will  usually  enable  the  surgeon  to  arrive  at  a  diagnosis  at  a  much  earlier 
period  than  would  otherwise  be  possible — an  advantage  to  the  patient 
which  should  well  repay  the  trouble  of  its  performance. 

Prognosis. — The  prognosis  in  brain  abscess  is  unfavorable.  When 
left  to  nature  or  treated  by  drugs,  recovery  is  exceedingly  rare.  Cases 
have  been  observed  in  which,  because  of  an  extensive  destruction  of  the 
tegmen  tympani  and  tegmen  antri,  an  opening  of  sufficient  dimensions 
has  been  provided  through  the  skull  to  furnish  free  drainage  to  the 
abscess  and  thus  provide  the  one  most  essential  condition  of  recovery. 
Even  where  good  drainage  is  by  this  means  provided,  the  abscess  cavity 
in  the  brain  is  constantly  subjected  to  the  possibilities  of  reinfection  from 
the  nearby  suppuration  of  the  mastoid  antrum  and  middle  ear  with 
which  it  is  connected,  and  ultimate  extension  of  the  brain  affection  and 
death  are  the  final  outcome.  A  natural  cure  may  result  from  the 
absorption  of  a  small  brain  abscess,  but  this  termination  must  be  reckoned 
among  the  rarest  possibilities.  As  has  been  previously  stated,  when 
the  abscess  becomes  encapsulated  by  thick  walls,  it  may  remain  appar- 
ently harmless  for  months,  years,  or  even  until  the  death  of  the  individual 
results  from  other  causes.  Most  usually,  however,  such  an  abscess 
sooner  or  later  ruptures  into  the  ventricles  or  upon  the  surface  of  the 
brain,  and  in  either  instance  death  speedily  follows. 

The  prognosis  following  surgical  interference  is  much  better  than 
when  the  case  is  left  to  nature  or  than  that  following  local  or 
medicinal  methods.  Macewen  states  that  when  the  abscess  is  diagnosed 
early,  its  position  in  the  brain  accurately  determined,  and  surgical 
measures  are  promptly  adopted,  cerebral  abscess  is  one  of  the  most 
hopeful  intracranial  affections.  It  must  be  remembered  that  this  ideal 


444  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

condition,  as  stated  by  Macewen,  is  very  seldom  met  with  in  actual 
practise,  and  that  in  the  past  a  large  majority  of  all  operations  that 
have  been  undertaken  for  the  relief  of  brain  abscess  have  been  performed 
at  a  late  stage  of  the  disease  and  as  a  last  resort.  Large  statistics  con- 
cerning the  percentage  of  recovery  in  brain  abscess  after  operation  have 
not  been  published,  but  from  the  sources  of  information  available  on 
this  point  it  would  seem  that  about  25  per  cent,  of  all  operated  cases 
get  well.  Of  the  author's  eight  cases  of  operation  for  cerebral  abscess, 
two  are  living  and  in  good  health  after  a  period  of  four  years.  One 
case  died  from  a  recurrence  of  the  abscess  after  a  period  of  several 
months  and  after  recovery  had  apparently  taken  place. 


CHAPTER  XXXV 

INTRACRANIAL    COMPLICATIONS    (Continued) 

THE    TREATMENT    OF   BRAIN   ABSCESS 

THE  treatment  of  brain  abscess  is  essentially  surgical.  While  a  few 
cases  have  been  known  to  recover  through  the  unaided  efforts  of  nature, 
such  a  result  is  too  rare  to  be  expected  and  should  never  be  awaited. 
When,  therefore,  the  diagnosis  has  with  certainty  been  made,  surgical 
measures  offer  the  only  hope  of  satisfactory  results;  and  even  when  the 
diagnosis  is  not  absolutely  certain,  but  when  all  the  symptoms  point 
to  intracranial  involvement,  and  the  examination  of  the  ear  leaves  no 
question  as  to  the  possibility  of  infection  from  this  source,  then  an 
exploratory  operation  is  entirely  justifiable  on  the  ground  that  the 
mastoid  infection  can  thereby  be  relieved,  the  adjacent  walls  of  the 
mastoid  cavity  can  be  accurately  inspected  for  sinuses  leading  into  the 
cranial  cavity,  and  the  condition  of  the  floor  of  the  brain  above  the 
mastoid  antrum  and  middle  ear,  together  with  the  groove  of  the  lateral 
sinus,  can  be  so  exposed  that  a  reliable  judgment  can  be  formed  as  to 
whether  or  not  the  infection  has  extended  to  the  brain  surfaces  or  sigmoid 
sinus.  If  still  in  doubt  concerning  the  matter,  no  hesitancy  should  be 
felt,  indeed  the  surgeon  should  consider  it  his  positive  duty,  to  uncover 
the  brain  above  and  the  sinus  posteriorly  to  an  extent  in  each  instance 
sufficiently  to  permit  the  palpation,  inspection,  and,  when  necessary, 
the  incision  of  the  dura  covering  the  sinus  or  that  overlying  the  teg- 
men.  Thus,  operative  procedures  are  sometimes  indicated  for  diagnostic 
purposes  for  the  reason  that  it  is  often  impossible  to  tell  beforehand 
with  certainty  in  exactly  what  portion  of  the  brain  the  abscess  is  located ; 
whether  it  is  extradural,  subdural,  cerebral,  or  cerebellar;  and  since  when 
an  abscess  is  present  in  any  of  these  locations  it  is  amenable  only  to 
surgical  methods  of  treatment,  it  makes  little  difference  whether  or  not 
the  previous  diagnosis  is  exact  in  so  far  as  its  precise  situation  in  the 
cranium  is  concerned,  provided  the  operator  is  prepared  to  deal  equally 
with  the  particular  condition  when  once  it  is  discovered. 

In  operations  for  the  relief  of  intracranial  disease  which  has  arisen 
as  a  result  of  aural  suppuration,  it  is  best  to  perform  the  complete  tym- 
panomastoid  exenteration  as  a  preliminary  step  (see  Fig.  251),  first,  be- 
cause in  this  way  only  can  the  original  foci  of  the  disease  be  eliminated; 

445 


446  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

second,  the  diagnosis  of  the  exact  condition  within  the  cranium  can  often 
be  made  out  only  after  the  performance  of  the  radical  mastoid  operation, 
and,  third,  the  channel  through  which  the  infection  traveled  to  the  brain 
is  thus  discovered,  if  present,  and  hence  great  advantage  will  be  gained 
by  following  this  communicating  channel  of  infection  in  the  subsequent 
steps  of  the  intracranial  surgery. 

Should  the  previous  symptoms  have  pointed  to  a  cerebral  abscess, 
the  roof  of  the  mastoid  antrum — the  tegmen  antri — should  be  removed 
if  this  has  not  already  been  done  during  a  previous  exploratory  operation, 
since  the  site  of  a  cerebral  abscess  of  the  temporosphenoidal  lobe,  when 
due  to  aural  infection,  is  nearly  always  in  the  immediate  vicinity  of  this 
portion  of  the  temporal  bone.  In  case  a  carious  opening  already  exists 
in  the  tegmen,  this  should  be  followed,  but  in  any  case  enough  of  the 
bone  between  the  antrum  and  dura  should  be  removed  (Fig.  277)  to 
enable  the  examiner  to  satisfactorily  inspect,  palpate,  or,  if  necessary, 
to  incise  the  dura.  Should  the  subdural  space  have  become  infected 
through  the  burrowing  of  pus  from  the  adjacent  osseous  cavities,  an 
extradural  abscess,  with  or  without  a  collection  of  pus  in  the  brain 
itself,  will  be  found. 

Surgical  Treatment  of  Extradural  Abscess. — When  this  form  of 
abscess  is  present  pus  immediately  pours, into  the  mastoid  wound  as 
soon  as  the  tegmen  antri  has  been  penetrated  by  the  gouge.  After  the 
bone  has  been  removed  over  a  sufficiently  large  area  to  permit  the 
introduction  of  the  dura  mater  separator,  this  instrument  should  be 
inserted  between  the  bone  and  dura  and  passed  in  every  direction,  at 
the  same  time  lifting  the  membrane  to  an  extent  that  will  insure  the  free 
outflow  of  any  pus  from  this  locality.  Care  should  be  taken  not  to 
introduce  the  separator  beyond  the  point  where  it  meets  with  even  slight 
resistance,  for  the  reason  that  protective  inflammatory  adhesions  have 
possibly  already  taken  place  between  the  dura  and  bone;  the  extradural 
abscess  is,  therefore,  a  limited  one,  and  any  loosening  of  the  adhesions 
by  the  separator  would  permit  a  spread  of  the  infection,  with  a  rapidly 
fatal  termination  from  the  resulting  meningitis. 

The  extradural  pus  having  been  thus  evacuated  and  the  exposed 
dural  area  dried,  a  further  examination  of  the  dura  should  be  made  to 
determine  if  subdural  abscess  is  present.  Should  a  cerebral  abscess 
lie  near  the  surface  at  this  point  the  dura  will  bulge  through  the  opening 
as  soon  as  the  underlying  bone  is  removed.  If  the  pus  is  confined  under 
much  pressure  the  membrane  will  appear  injected,  dark,  or  gray,  de- 
pending upon  the  stage  of  the  disease,  and  no  pulsation  will  be  felt  when 
the  examining  finger  is  placed  upon  it.  If  sufficient  bone  has  been 


INTRACRANIAL   COMPLICATIONS  447 

removed  to  permit  palpation  of  the  exposed  dura,  fluctuation  may  be 
detected  in  the  protruding  part.  In  case  none  of  these  conditions  are 
found  present  it  may  be  reasonably  supposed  that  the  extradural  abscess 
was  the  sole  cause  of  the  previous  intracranial  symptoms,  and  the  operation 
may,  therefore,  be  concluded  by  placing  a  thin  wick  of  iodoform  gauze 
between  the  dura  and  bone,  after  which  the  mastoid  is  dressed  in  the 
usual  manner.  Should,  however,  the  examination  of  the  exposed  dura 
indicate  the  presence  of  pus  in  the  brain,  this  must  be  at  once  evacuated. 
Treatment  of  Temporosphenoidal  Abscess  (Fig.  275). — If  the  dura 
mater  at  the  seat  of  the  exposure  above  the  mastoid  antrum  or  of  that 
overlying  the  attic  of  the  middle  ear  is  black  or  grayish  and  bulging,  it 
should  be  incised  in  this  location  even  though  it  is  afterward  deemed 


Median  fissure 


Opening  into 
abscess  cavity 


FIG.  275. — LARGE  TEMPOROSPHENOIDAL  ABSCESS. 


advisable  to  trephine  the  skull  at  some  point  above  the  external  auditory 
meatus,  and  to  connect  this  latter  opening  with  the  mastoid  wound  below. 
The  author  is  aware  that  any  method  of  operating  which  provides  an 
opening  into  the  abscess  so  as  to  connect  it  with  the  mastoid  wound  is 
open  to  the  criticism  that  the  latter  is  a  septic  cavity  which  remains  a 
constant  menace  to  the  subsequent  healing  of  the  cerebral  abscess. 
Nevertheless,  when  the  abscess  is  located  over  the  tegmen  antri  or  teg- 
men  tympani,  as  above  described,  the  advantage  secured  by  the  drain- 
age of  the  bottom  of  the  abscess  into  the  mastoid  wound  is  so  great 
that  the  objection  of  likelihood  of  reinfection  is  of  minor  importance. 
Especially  is  this  true  when  the  precaution  is  taken  at  the  subsequent 
dressings  not  to  disturb  the  cerebral  wound  until  the  cavity  of  the  mas- 
toid has  first  been  cleansed  and  packed  with  iodoform  gauze. 


448  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

When  the  abscess  cavity  is  very  large  or  in  case  it  is  not  thought 
advisable  to  open  and  drain  it  through  the  tegmen,  the  incision  through 
the  skin  and  soft  parts  is  extended  as  shown  in  Fig.  276,  CD.  A  nap 
with  the  pinna  at  its  base  is  turned  downward  and  forward  (Fig.  277) 
and  a  trephine  with  a  diameter  of  f  inch  is  applied  to  the  skull  i  \  inches 
above  Reid's  base  line  at  a  point  perpendicularly  above  the  opening  of  the 
external  auditory  meatus.  The  button  of  bone  which  is  removed  should 
be  placed  in  a  vessel  of  warm  sterilized  normal  salt  solution  for  preser- 
vation until  it  is  determined  whether  or  not  it  is  advisable  to  replace  the 


FIG.  276. — LINKS  OF  PRIMARY  INCISION  FOR  OPENING  THE  MASTOID  AND  MIDDLE  CRANIAL  FOSSA  FOR  THE 

REMOVAL  OF  DISEASED  PRODUCTS  DUE  TO  EXTENSION  FROM  THE  EAR. 
AB,  the  line  of  incision  for  the  preliminary  mastoid  operation.      CD,  line  of  extension  for  making  temporal  flap. 

same  in  the  trephine  opening  before  closing  the  wound.  If  upon  ex- 
posure the  dura  is  found  to  have  a  normal  color  and  to  pulsate  and  if  no 
other  evidence  of  an  abscess  exists,  then  the  button  may  be  replaced 
either  whole  or  comminuted  and  the  skin  flap  may  be  completely 
sutured  over  it  in  its  proper  place.  Should,  however,  the  dura  be  found 
to  bulge  at  once  through  the  trephine  opening,  as  shown  in  Fig.  277,  to 
be  free  from  pulsation,  of  a  dark  or  gray  color,  and  to  give  other 
evidences  of  the  presence  of  fluid  beneath  it,  an  incision  should  at  once 
be  made  through  the  membrane  and  an  exploration  of  the  brain  be  in- 
stituted for  the  discovery  of  the  abscess.  Sometimes  thick  pus  will  be 


INTRACRAN1AL    COMPLICATIONS 


449 


found  upon  the  inner  surface  of  the  dura,  whereas,  occasionally  when 
this  membrane  is  incised,  the  pus  escapes  at  once,  there  being  no  other 
intervening  tissue  separating  the  abscess  cavity.  When  the  pus  is  con- 
fined under  pressure  and  is  thin  in  consistency,  as  is  frequently  the  case 
in  acute  brain  abscesses,  it  may  spurt  into  the  air  a  foot  or  more  im- 
mediately after  it  is  liberated  by  the  incision. 

In  case  the  abscess  occupies  a  deeper  situation  it  becomes  necessary 
to  incise  the  dura  more  extensively,  and  this  is  most  satisfactorily  accom- 


Periosteum  "If 
of  flap 


Dura  mater 


Dura  mater 
over  legmen 
'    antri 

U  Oval  window 
•j  Remnant  post- 
"~  meatal  wall 

j^j  Sigmoid  sinus 


FIG.  277. — COMPLETE  MARTOID  EXEVTERATIOX  snowixr,  EXPOSURE  or  THE  DVISA  OVER  THE  TEGMEN  ANTRI 

AND  OVER  A  PORTION  OF  THE  SlGMOID  SlNUS. 

The  incision  has  been  extended,  following  the  mastoid  operation,  along  the  lines  shown  in  Fig.  276,  and 
a  temporal  flap  including  the  soft  structures  of  the  external  auditory  meatus  and  the  auricle  has  been  turned 
down.  A  button  of  the  squama  has  been  removed  with  the  trephine  showing  the  bulging  dura  mater  of  the 
temporosphenoidal  lobe. 

plished  by  cutting  a  flap  from  its  exposed  surface.  This  flap  should 
have  its  base  at  a  point  in  the  wound  exactly  opposite  that  of  the  skin 
flap,  namely,  at  the  upper  posterior  portion  of  the  trephine  opening. 
A  small  sharp  bistoury  is  used  for  making  this  incision,  which  should 
follow  parallel  to  the  bony  margin  and  y1^-  inch  from  it.  Some- 
times large  veins  traverse  the  dura  and  these  should  be  avoided  where 
possible,  since  the  bleeding  which  results  from  their  division  obscures 

29 


450  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

the  field,  and  it  is  difficult  to  arrest  blood  coming  from  vessels  so  difficult 
to  clamp  or  tie. 

After  the  reflection  of  the  dural  flap  the  operator  should  note  care- 
fully the  relation  of  the  exposed  portion  of  brain  to  the  petrous  portion 
of  the  adjacent  temporal  bone  below,  and  should  recall  the  most  frequent 
sites  in  which  abscess  in  this  portion  of  the  cerebrum  is  found.  Temporo- 
sphenoidal  abscesses  are  near  those  portions  of  the  petrous  which  are 
most  frequently  carious  and  which  give  rise  to  the  brain  infection — 
namely,  the  tegmen  antri  and  tegmen  tympani.  By  bearing  this  fact 
in  mind  the  surgeon  will  frequently  avoid  needless  wounding  of  the 
brain  structure  in  his  attempts  to  locate  the  seat  of  the  collection  of  pus. 
The  exploring  instrument  should,  therefore,  be  first  passed  in  the 
direction  of  the  tegmen  antri,  after  which,  if  unsuccessful,  it  may  be 
directed  toward  the  tegmen  tympani,  and  then  again  along  the  adjoining 
surface  of  the  petrous  portion. 

The  kind  of  instrument  used  for  this  exploration  is  of  importance. 
Formerly  an  aspirating  needle  or  a  hollow  trocar  was  employed,  but 
was  found  entirely  unsatisfactory.  Any  hollow  needle  or  canula  is 
apt  to  become  filled  with  brain  tissue,  and  this  class  of  instrument  has, 
therefore,  been  known  to  penetrate  the  abscess  without  any  pus  appear- 
ing in  the  canula  to  demonstrate  that  fact.  On  the  other  hand,  such 
an  instrument  may  pass  entirely  through  a  small  abscess  and  thus 
deceive  the  examiner  as  to  the  real  condition  within.  Ballance  (Lancet, 
May  25,  1901)  advocates  the  use  of  a  sharp-pointed,  long  and  narrow 
knife  as  the  best  exploring  instrument,  and  states  that  not  only  is  the 
abscess  more  certainly  discovered  by  means  of  such  an  instrument,  but 
that  the  clean-cut  wound  produced  by  it  in  the  cerebral  tissue  heals 
more  readily  than  when  produced  by  other  instruments.  In  very 
chronic  cases  of  brain  abscess,  when  the  pus  is  contained  within  a 
strong  capsule,  it  is  possible  not  to  enter  the  cavity  even  when  a  sharp 
knife  is  used  in  exploration.1 

1  Ballance  reports  such  a  case  in  which  the  abscess  was  missed  during  explorations  at 
the  time  of  the  operation.  Post-mortem  examination  revealed  the  presence  of  an  abscess 
containing  4  ounces  of  pus  which  was  contained  in  a  capsule  so  dense  that  the  abscess 
could  be  hulled  out  without  rupture  and  rolled  about  upon  the  table.  The  author  had 
a  similar  experience.  A  large  temporosphenoidal  abscess  had  been  evacuated  three 
months  previously,  and  the  patient  was  thereby  supposedly  cured.  A  return  of  the  old 
symptoms  resulted  in  a  second  operation  and  evacuation  of  a  secondary  abscess.  The 
patient's  symptoms  did  not  improve  and  he  was  comatose  in  two  weeks  from  the  time 
of  the  second  operation.  At  the  beginning  of  the  unconscious  state  a  sharp  knife  was 
passed  into  the  brain  in  every  direction  without  discovering  further  abscess  formation. 
At  the  autopsy  a  firmly  encapsulated  abscess  was  found  which  had  lain  directly  in  the 
track  of  the  exploration.  So  resisting  and  thick  were  the  walls  of  this  cavity  that  a  sharp 
thrust  of  a  pointed  knife  was  required  to  penetrate  it. 


INTRACRANIAL   COMPLICATIONS  451 

If  the  abscess  cavity  lies  in  the  direction  of  the  tympanic  or  antral 
roof  and  is  near  the  cerebral  surface,  a  counteropening  into  the  mastoid 
wound  is  indicated  for  the  purpose  of  securing  the  best  possible  drainage. 
It  sometimes  happens  that  the  abscess  is  located  somewhat  above, 
either  anteriorly  or  posteriorly  to  the  center  of  the  trephine  opening, 
and  that,  therefore,  its  cavity  cannot  be  satisfactorily  explored  or  sub- 
sequently treated  through  the  small  and  improperly  placed  trephine 
opening  which  has  already  been  made.  In  this  instance  the  osseous' 
wound  must  be  enlarged  in  the  direction  of  the  abscess  to  an  extent 
that  the  center  of  the  abscess  lies  approximately  under  the  extended 
portion  of  the  osseous  wound.  The  removal  of  any  additional  portions 
of  the  skull  for  the  above  or  other  reasons  is  best  accomplished  by  means 
of  the  Hoffman's  or  DeVilbiss  forceps,  with  either  of  which  the  portion 
of  bone  to  be  removed  can  be  quickly  surrounded  by  the  narrow  trench 
which  is  made  through  both  tables  of  the  skull,  and  the  area  thus  set 
free  can  be  lifted  out.  While  the  removal  of  any  unnecessary  portion 
of  the  skull  should  always  be  avoided  on  account  of  the  increased  tend- 
ency to  hernia  cerebri  or  of  the  subsequent  liability  to  the  formation  of 
adhesions  between  the  dura  and  skin  flap,  nevertheless  when  greater 
advantage  can  be  thereby  secured  in  the  way  of  a  better  examination 
and  cleansing  of  the  abscess  cavity  at  the  time  of  operation  and  in  the 
subsequent  dressing  of  the  case,  the  operator  should  not  hesitate  to  cut 
away  an  area  of  skull  sufficient  for  these  purposes.  After  the  evacuation 
of  all  pus  it  may  be  found  that  inspissated,  cheesy  material  or  brain 
sloughs  yet  remain  in  the  abscess  cavity  which  are  too  thick  in  con- 
sistency to  flow  out  with  the  other  material.  These  may  be  cautiously 
washed  away  with  sterilized  normal  salt  solution,  ample  provision 
having  first  been  made  for  the  free  return  of  the  fluid.  Or,  in  case  it 
is  deemed  more  advisable  to  do  so,  any  remaining  sloughs  may  be 
removed  by  the  most  gentle  use  of  the  curet.  When  the  cavity  is  thus 
cleared  of  septic  matter  it  is  advantageous  to  learn  the  character  of 
the  retaining  walls  of  the  abscess.  For  the  purpose  of  exploration  the 
little  finger  may  be  inserted  and  passed  in  every  direction  over  the 
interior  surface.  Whiting  has  devised  an  encephaloscope  (Fig.  278), 
which  when  inserted  into  the  cavity,  the  interior  of  which  is  subsequently 
illuminated  by  reflected  light,  enables  the  examiner  to  actually  see  the 
interior  surface,  to  judge  the  strength  of  the  limiting  membrane,  and 
possibly  to  discover  any  granulations  or  fistula  that  are  present.  The 
information  thus  gained  is  of  great  value  in  the  subsequent  management 
of  the  case.  Should  it  be  found  that  the  abscess  is  a  very  chronic  one 
and  that  it  is,  therefore,  completely  walled  off  from  the  adjoining 


452 


THK    PRINCIPLES    AND    PRACTICK    OF    OTOLOGY 


brain  substance  by  a  thick  partition  of  connective  tissue,  the  subsequent 
irrigation  or  other  manipulation  necessary  for  cleansing  and  drainage 
may  be  accomplished  with  much  less  danger  than  would  be  the  case 
if  the  abscess  were  acute  and  no  capsule  whatever  were  present. 

Although  an  acute  brain  abscess  may  be  large,  and  a  large  cavity  be 
present  immediately  after  its  evacuation,  the  elasticity  of  the  surrounding 
cerebral  tissue  has  not  yet  been  lost,  and  there  being  present  no  retaining 
"capsule,  the  space  occupied  by  the  abscess  is  quickly  encroached  upon 
by  adjacent  cerebral  substance  and  is  soon  obliterated.  In  this  class 
of  abscess,  therefore,  it  is  necessary  to  cleanse  the  cavity  of  all  pus  and 
necrotic  brain  at  the  time  of  the  operation  if  this  be  possible,  and  to 
make  provision  for  drainage  by  such  means  as  will  not  interfere  with 


FIG.  278. — WHITING'S  ENCEPHALOSCOPES. 


the  rapid  closure  of  the  space  by  the  natural  method  of  brain  expansion. 
The  space  resulting  from  the  evacuation  of  an  acute  abscess  should  not, 
therefore,  be  packed  with  gauze,  but  if  this  material  is  selected  as  the 
method  of  dressing  and  drainage,  only  a  thin  strip  should  be  inserted 
to  the  bottom,  a  few  folds  of  which  strip  should  be  loosely  placed  one 
over  the  other  and  ample  space  be  provided  about  the  point  of  its 
emergence  at  the  dural  opening. 

When  the  abscess  is  chronic  and  is  surrounded  by  thick  walls, 
no  such  expansion  of  the  brain  occurs,  and  the  cavity  must,  therefore, 
be  ultimately  healed  by  granulation.  The  gauze  dressing  is  more 
suited  in  this  than  in  acute  cases.  A  strip  of  iodoform  gauze  A  inch 
wide,  with  selvage  edge,  should  be  seized  near  one  end  between  the  jaws 


INTRACRANIAL   COMPLICATIONS  453 

of  a  slender  dressing-forceps,  and  the  same  should  be  inserted  through 
the  encephaloscope,  first  to  the  remotest  part  of  the  abscess  cavity,  and 
then  over  this  coils  of  the  strip  are  properly  placed  one  upon  another. 
The  whole  work  of  packing  the  abscess  must  be  carried  out  by  means  of 
reflected  light,  until  finally  the  entire  space  is  snugly  but  not  tightly  filled. 

In  the  case  of  either  an  acute  or  chronic  abscess  if  a  counteropening 
has  been  made  through  the  tegman  antri  or  tympani,  the  strip  of  gauze 
which  is  inserted  through  the  trephine  opening  above  should  be  brought 
out  through  the  lower  opening  into  the  mastoid  wound,  since  from  this 
plan  the  most  perfect  drainage  will  be  secured. 

Instead  of  the  gauze  dressing  just  described,  many  operators  prefer 
to  use  a  glass  or  soft-rubber  drainage-tube;  and  when  a  tube  is  selected 
and  a  counteropening  has  been  provided,  one  end  of  the  drain  should 
emerge  from  the  upper  or  trephine  opening  and  the  other  through  that 
in  the  tegmen,  while  the  intervening  perforated  portion  passes  through 
the  abscess  cavity. 

In  case  gauze  has  been  used  to  fill  the  cavity  and  a  counteropening 
has  been  provided  through  the  tegmen,  the  gauze  should  be  so  arranged 
in  the  upper  opening  that  none  lies  external  to  the  dura.  If  not  too 
much  mutilated  or  diseased,  the  flap  of  dura  mater  may  then  be  replaced 
and  the  skin  flap  should  be  stitched  into  its  proper  position  by  means  of 
interrupted  catgut  sutures.  All  subsequent  dressings  are  made  through 
the  opening  in  the  tegmen.  If  in  any  case  it  is  thought  necessary  to 
insert  a  drainage-tube  through  the  upper  opening  and  to  bring  it  out  at 
the  lower,  it  will  be  advisable  to  cut  a  hole  through  the  skin  flap  large 
enough  to  accommodate  the  upper  end  of  the  tube,  which  is  inserted 
through  this  hole  in  the  flap,  and  which  latter  is  then  completely  sutured 
in  place  as  before  described. 

In  either  instance  the  mastoid  wound  is  dressed  separately  from 
that  within 'the  cranial  cavity  and  in  the  usual  way.  That  portion  of 
the  drainage-tube  leading  from  the  abscess  cavity  through  the  tegmen 
should  not  be  perforated  external  to  its  point  of  exit  through  the  dura, 
and  this  unperf  orated  part  should  be  long  enough  to  pass  entirely  through 
the  mastoid  dressings.  The  observance  of  this  precaution  concerning 
the  preparation  of  the  tube  will  prevent  the  leakage  of  pus  from  above 
into  the  mastoid  dressings,  and  will  avoid  to  some  extent,  at  least,  the 
introduction  of  sepsis  from  the  mastoid  into  the  abscess  cavity  above. 

Boric  acid  powder  or  other  antiseptic  may  be  dusted  over  the  line 
of  flap  sutures;  a  large  quantity  of  loose  gauze  is  placed  over  the  end  of 
the  drainage-tube  to  absorb  the  exuded  pus,  and  the  operation  is  com- 
pleted by  the  application  of  the  roller  bandage. 


454  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

The  management  of  the  after-treatment  is  of  the  greatest  importance, 
for  upon  the  care  and  intelligence  with  which  this  is  carried  out  success 
or  failure  will  greatly  depend.  Both  pulse  and  temperature,  if  pre- 
viously subnormal,  will  at  once  regain  the  normal  and  may  be  slightly 
elevated.  If  the  patient  was  comatose,  or  if  paralysis  of  some  portion 
of  the  body,  or  of  certain  groups  of  muscles  was  previously  present, 
but  of  short  duration,  and  if  the  nerve  center  for  these  had  not  been 
destroyed,  the  function  of  the  parts  will  be  at  once  restored  or  at  least 
greatly  improved.  Consciousness  will  be  regained,  sometimes  almost 
as  soon  as  the  patient  comes  from  under  the  anesthetic.  Previous  pain 
and  tendency  to  eject  all  nourishment  often  disappears  at  once.  The 
appetite,  which  had  for  days  been  entirely  wanting,  returns  with  a  most 
gratifying  sharpness.  The  previously  dull  mental  state  is  changed 
to  one  of  acute  rational  activity,  the  patient  being  sometimes  unusually 
talkative  and  joyous.  All  former  power  of  cerebration  may  be  again 
resumed  just  as  though  no  serious  injury  to  a  considerable  portion 
of  the  brain  had  ever  occurred.  Indeed,  few  diseases  present  more 
marked  and  sudden  changes  for  the  better  than  those  which  follow  the 
successful  evacuation  of  an  uncomplicated  cerebral  abscess. 

The  subsequent  symptoms  will  determine  the  time  of  changing  the 
first  dressing.  If  the  patient's  condition  remains  satisfactory  as  to 
temperature,  pulse,  and  freedom  from  pain,  and  if  the  dressings  remain 
dry  and  sweet  smelling  the  dressing  should  not  be  disturbed  for  four 
or  five  days.  On  account  of  the  very  free  discharge  wrhich  follows, 
particularly  in  cases  of  large  chronic  brain  abscesses,  the  dressings  are 
badly  soiled  much  earlier  than  this  and  will  need  changing.  In  fact, 
the  amount  of  subsequent  suppuration  from  a  chronic  abscess  is  usually 
very  profuse,  and  will,  therefore,  require  frequent  changes  of  the  gauzes. 
If  at  the  time  of  the  operation  the  cavity  was  filled  with  gauze  it  may  be 
found  that  pressure  symptoms  rapidly  develop,  which  will  require  an 
early  investigation  of  the  wound.  It  may  then  be  found  that  the  gauze 
has  been  rapidly  saturated  with  the  exudates  and  that  it  has  hindered 
rather  than  facilitated  the  drainage  from  the  abscess  cavity.  Should 
this  be  found  to  be  the  case,  a  soft-rubber  drainage-tube  should  be 
immediately  substituted  for  the  gauze  packing. 

Some  difference  of  opinion  exists  as  to  whether  or  not  a  brain  abscess 
should  be  cleansed  by  syringing.  It  is  certain  that  rude  and  unskilful 
methods  of  syringing  in  this  class  of  cases  would  result  in  harm.  In 
the  acute  abscess,  even  the  most  gentle  syringing  might  wash  away 
portions  of  the  unprotected  brain  substance;  but  in  chronic  cases  where 
a  thick-walled  capsule  exists  and  no  fistulae  are  present,  this  method 


INTRACRANIAL   COMPLICATIONS  455 

of  cleansing  ought  to  be  safe  if  used  with  caution,  and  if  ample  provision 
is  made  for  the  free  escape  of  the  injected  fluid.  When  the  interior 
of  such  a  chronic  abscess  cavity  can  be  inspected  by  means  of  the  en- 
cephaloscope  and  reflected  light,  excessive  granulation  tissue  may  be 
cauterized  or  even  removed.  This  class  of  cases  heals  by  granulation 
and  it  should  be  the  aim  of  the  operator  to  secure  firm,  healthy  granula- 
ting surfaces  in  all  directions,  to  the  end  that  the  space  within  is  finally 
obliterated,  much  after  the  manner  of  the  closure  of  a  frontal  sinus 
subsequent  to  an  operation  and  treatment  by  the  open  method. 

In  the  after-treatment  of  the  acute  case  the  gauze  strip  or  drainage- 
tube  which  was  inserted  at  the  time  of  the  operation  should  at  subsequent 
dressings  be  gradually  withdrawn  and  cut  off  as  rapidly  as  the  expansion 
of  the  brain  takes  place,  to  the  end  that  this  provision  for  drainage  shall 
at  no  time  become  a  hindrance  to  the  closure  of  the  cavity  through  the 
natural  resumption  by  the  brain  of  its  original  dimensions,  after  once 
the  local  pressure  of  the  abscess  is  removed. 

In  cases  where  it  was  necessary  at  the  time  of  the  operation  to  remove 
a  considerable  portion  of  the  skull  in  order  to  reach  and  thoroughly 
expose  the  abscess,  a  hernia  cerebri  may  subsequently  develop.  This 
occurrence  may  be  hastened  or  even  caused  by  faulty  technic  at  the 
time  of  the  operation  or  by  the  subsequent  admission  of  additional 
septic  material  into  the  wound.  Every  precaution  should,  therefore, 
be  taken  at  all  times  to  avoid  infection.  Should  such  a  hernia  occur, 
it  is  best  treated  by  means  of  sterilized  antiseptic  dressings,  but  if  it 
does  not  subside  rapidly  from  this  measure  it  may  be  cauterized  with 
silver  nitrate  or  the  extruded  mass,  which  consists  largely  of  granulation 
tissue,  may  be  excised.  Proper  arrangement  of  gauze  pads  over  the 
hernia  and  the  application  of  slight  pressure  by  the  bandages  will 
sometimes  satisfactorily  relieve  this  annoying  condition. 

The  convalescence  may  be  interrupted  by  meningitis  or  by  the 
formation  of  a  secondary  abscess.  The  appearance  of  either  of  these 
serious  complications  will  be  accompanied  by  the  symptoms  indicative 
of  the  respective  disease.  Thus,  the  occurrence  of  a  chill,  accompanied 
by  fever,  a  rapid  pulse,  and  a  general  headache  would  indicate  that 
leakage  from  the  abscess  had  occurred  and  that  a  general  meningitis 
had  resulted.  On  the  other  hand,  an  abnormal  slowing  of  the  pulse, 
a  subnormal  temperature,  a  localized  pain  over  the  affected  side  accom- 
panied by  vomiting,  would  be  almost  positive  evidence  that  either  a 
new  abscess  had  formed  or  that  the  original  one  is  badly  drained.  Sec- 
ondary operation  is  indicated  at  once  when  the  symptoms  of  an  additional 
abscess  or  of  the  refilling  of  the  former  one  are  well  marked. 


CHAPTER  XXXVI 

INTRACRANIAL    COMPLICATIONS    (Continued) 

CEREBELLAR    ABSCESS 

THE  etiology  and  pathology  of  this  affection  have  already  been 
discussed  in  the  chapter  which  dealt  in  a  general  way  with  the  intra- 
cranial  complications  (see  Chapter  XXX.).  Moreover,  in  the  several 
sections  of  the  work  relating  to  the  suppurative  disease  of  the  tem- 
poral bone,  it  has  frequently  been  pointed  out  that  cerebellar  abscess 
may  occur  as  a  complication  of  any  infection  existing  in  the  middle  ear, 
mastoid  antrum,  or  mastoid  cells. 

Symptoms. — The  symptoms  of  a  collection  of  pus  in  the  cerebellum 
are  often  vague  and  misleading..  In  many  instances  the  symptoms  may 
be  such  as  to  lead  the  examiner  to  the  belief  that  an  intracranial  compli- 
cation exists,  but  are  not  indicative  of  its  exact  character  or  location. 
Some  cases  are  throughout  a  long  period  of  the  existence  of  the 
cerebellar  abscess  entirely  symptomless,  in  so  far  as  suggesting  a  disease 
of  the  cerebellum  is  concerned.  A  discharging  ear  is,  of  course,  always 
present  or  there  is  a  history  of  such  a  discharge  having  at  one  time  been 
present.  The  discharge  may  be  profuse  or  scant  and  is  often  foul 
smelling  and  sanious.  The  abscess  may  follow  either  an  acute  or 
chronic  aural  affection.  Many  of  the  symptoms  wrhich  are  present 
belong  to  the  progress  of  the  original  aural  disease  which  has  finally  led 
up  to  the  cerebellar  abscess.  Thus,  for  many  years  the  carious  proc- 
esses incident  to  a  chronic  aural  discharge  may  be  going  on  in  some 
portion  of  the  cellular  structure  of  the  temporal  bone.  During  this 
time  more  or  less  pain,  deeply  seated  in  the  ear,  may  have  been  present. 
The  history  of  one  or  more  attacks  of  mastoiditis  may  be  given,  and 
headaches,  vertigo,  and  nystagmus  may  at  some  time  have  formed  a 
more  or  less  prominent  symptom.  The  abscess  may  have  been  present 
for  a  long  time,  and  not  having  produced  symptoms  more  numerous  or 
severe  than  the  foregoing,  the  patient  continues  his  usual  occupation  and 
perhaps  has  never  regarded  his  trouble  as  sufficiently  serious  to  justify 
him  in  seeking  medical  advice.  It  is  only,  therefore,  when  the  above 
symptoms  become  aggravated  and  the  patient  is  no  longer  able  to  pursue 
his  business  that  the  surgeon  is  given  opportunity  to  investigate  the 
nature  of  the  affection. 

456 


INTRACRANIAL    COMPLICATIONS  457 

In  the  most  typic  cases  the  pain  is  located  in  the  occipital  region. 
The  pulse  and  temperature  are,  in  the  uncomplicated  affection,  subnormal, 
and  may,  as  in  the  case  of  a  cerebral  abscess,  be  very  much  reduced. 
When  the  abscess  is  large  the  respiration  is  also  greatly  affected,  being 
slower  than  normal,  and  in  the  worst  cases  may  be  both  slow  and  irreg- 
ular. Optic  neuritis  occurs  in  about  one-third  of  the  cases,  and  in 
some  amounts  to  a  complete  blindness.  In  this  affection,  as  in  brain 
abscess,  slow  cerebration  and  difficulty  on  the  part  of  the  patient  in  com- 
prehending what  is  said  are  often  prominent  symptoms. 

Objective  Symptoms. — The  patient  may  appear  robust  and  healthy 
unless  severe  pain,  vertigo,  and  digestive  disturbances  have  been  present, 
in  which  case  a  worn  and  cachectic  look  may  characterize  the  disease. 
A  physical  examination  of  the  ear  may  furnish  evidence  indicative  of 
extensive  necrosis  of  the  temporal  bone.  There  may  be  postauricular 
fistulae,  which  indicate  in  a  measure  the  extent  of  the  osseous  necrosis, 
as  well  as  the  continued  activity  of  the  suppurative  process.  Percussion 
over  the  occipital  region  of  the  affected  side  frequently  gives  rise  to  deep- 
seated  pain. 

Diagnosis. — The  above  symptoms  may  in  any  case  be  sufficiently 
numerous  and  so  well  denned  as  to  point  with  more  or  less  certainty  to 
the  presence  of  a  cerebellar  abscess.  Early  in  the  disease,  however,  it 
is  seldom  possible  to  make  a  positive  diagnosis,  and  hence  in  any  case 
in  which  cerebellar  complication  is  strongly  suspected  it  is  advantageous 
to  place  the  patient  in  charge  of  a  competent  nurse  with  instructions  to 
note  and  record  every  symptom  as  it  occurs,  for  by  exercising  this  pre- 
caution a  much  earlier  conclusion  as  to  the  nature  of  the  case  is  often 
possible. 

In  many,  however,  a  diagnosis  based  upon  the  symptoms  alone  is 
not  possible.  In  such  instances,  if  a  chronic  discharging  ear  is  present, 
if  there  is  evidence  of  extensive  mastoid  necrosis,  and  if  there  is  a  history 
of  pain,  vertigo,  and  perhaps  nystagmus,  the  radical  mastoid  operation 
is  indicated  as  a  diagnostic  measure.  During  this  operation  fistulous 
channels  may  be  found  leading  through  the  tegmen  tympani  or  antri  and 
involvement  of  the  middle  cerebral  fossa  may  be  present,  whereas  it  was 
supposed,  previously  to  opening  the  mastoid,  that  the  posterior  cranial 
fossa  was  involved.  The  reverse  of  this  statement  may  likewise  be  true, 
and  either  discovery  will  justify  the  exploratory  procedure. 

Treatment. — The  treatment  is  essentially  surgical,  and  like  that  for 
all  other  intracranial  suppurative  processes,  the  operation  for  the  evac- 
uation of  the  pus  should  be  performed  as  soon  as  the  diagnosis  is  made 
with  certainty  or  as  soon  as  its  presence  is  strongly  suspected.  Since  this 


458  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

class  of  abscess  may  be  the  result  of  a  rupture  of  pus  directly  from  the 
mastoid  portion  of  the  temporal  bone  backward  into  the  sigmoid  groove 
(Fig.  267),  or  may  occur  as  a  sequence  to  the  entrance  of  pyogenic  matter 
into  the  cerebellar  fossa  by  way  of  the  tympanic  cavity  and  labyrinth, 
and  from  thence  along  the  sheath  of  the  auditory  nerve  to  the  cerebellar 
fossa,  the  surgical  technic  for  the  evacuation  of  the  abscess  varies,  there- 
fore, somewhat  accordingly  as  to  whether  the  collection  is  located  anterior 
to  the  sigmoid  sinus  and  in  close  relation  to  the  adjacent  petrous  portion 
of  the  temporal  bone,  or  as  to  whether  it  is  posterior  to  the  sinus  and  in 
the  substance  of  the  adjoining  portion  of  the  cerebellum.  In  either 
instance  if  the  mastoid  operation  has  not  already  been  performed,  this 
should  be  done  at  once,  and  in  addition  the  bone  should  be  removed 
posteriorly  from  the  mastoid  wound  for  a  distance  sufficient  to  uncover 
the  sigmoid  sinus,  exactly  as  has  already  been  advised  in  operations  upon 
the  sinus  itself.  If  pus  is  found  surrounding  the  sinus,  the  bone  should 
be  removed  inward  and  backward  to  a  sufficient  extent  to  evacuate  the 
same,  and  to  determine  whether  or  not  it  may  have  formed  a  fistulous 
channel  leading  to  the  cerebellum  in  any  direction.  A  cerebellar  abscess 
and  a  lateral  sinus  thrombosis  may  both  exist  in  the  same  case,  and  hence 
the  sinus  itself  should  receive  at  this  time  an  inspection  such  as  has  been 
previously  indicated  (see  p.  426).  Any  fistula  that  is  discovered  in  the 
bone  as  the  operation  progresses  must  be  followed  to  its  source;  and  if 
necessary  for  this  purpose  additional  bone  may  be  removed  in  the 
direction  taken  by  the  fistulous  channel.  Should  the  perisinuous  pus 
be  found  to  exude  from  the  anterior  and  deeper  portions  of  the  wound 
adjacent  to  the  sinus,  the  fact  would  indicate  the  probability  of  its 
labyrinthine  origin,  and  the  dura  should,  therefore,  be  lifted  from  the 
cerebellar  surface  of  the  petrous  portion  of  the  temporal  bone,  provided 
the  collection  of  pus  is  seen  to  be  extradural.  The  instrument  best 
suited  for  this  extradural  exploration  is  the  blunt  separator  of 
Horsely.  The  separator  should  not  be  introduced  to  a  depth  of  more 
than  £  inch  measured  from  the  anterior  lip  of  the  groove  for  the 
lateral  sinus,  for  the  reason  that  the  facial  and  auditory  nerves  may  be 
injured  at  a  greater  depth  at  their  point  of  entrance  into  the  internal 
auditory  meatus.  The  auditory  nerve  may  be  already  destroyed  by 
the  necrosis,  but  the  function  of  the  facial  nerve,  if  still  active,  should, 
if  possible,  be  preserved. 

In  case  the  location  of  the  abscess  has  been  previously  and  definitely 
determined  to  be  posterior  to  the  sigmoid  sinus,  much  time  would  be 
saved  by  trephining  directly  into  the  cerebellar  fossa  without  first  per- 
forming the  mastoid  operation  and  afterward  continuing  the  removal  of 


INTRACRANIAL   COMPLICATIONS 


459 


bone  in  a  backward  direction,  as  above  advocated.  When  this  plan  is 
chosen  a  flap  of  the  skin  and  soft  tissues  extending  to  the  bone  is 
turned  upward.  The  center-pin  of  the  trephine  is  then  placed  on 
the  bone  at  a  point  i|  inches  posterior  to  the  center  of  the  external 
meatus,  and  J  inch  below  Reid's  base  line,  at  which  point  the  an- 
terior edge  of  the  instrument  will  not  injure  the  descending  portion 
of  the  sinus.  In  this  position  the  upper  edge  of  the  trephine  rests  just 
below  Reid's  base  line,  and  hence  the  horizontal  portion  of  the  lateral 
sinus  will  lie  above  and  well  out  of  harm's  way  (Fig.  279).  A  button  of 


FIG.  279. — POINTS  OF  ELECTION  ON  SKULL  FOR  OPENING  THE  MIDDLE  CEREBRAL  AND  CEREBELLAR  FOSSA. 
Also  the  relation  of  the  suprameatal  triangle  to  the  floor  of  the  middle  fossa,  and  to  the  lateral  sinus.     From 
the  points  of  election  for  trephining  here  shown,  the  bone  may  be  removed  in  any  necessary  direction  until 
the  required  area  of  dura  mater  has  been  exposed.     A',  suprameatal  triangle. 

bone  is  here  removed  and  the  opening  may  then  be  enlarged  with  bone 
forceps  backward  and  downward  as  far  as  necessary,  or  at  least  to  the 
extent  that  ij  inches  of  dura  are  exposed  in  a  vertical  and  anteropos- 
terior  direction.  Enlargement  of  the  trephine  opening  in  an  anterior 
direction  is  not  usually  advisable  on  account  of  the  course  of  the  sinus  in 


460  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

front,  but  if  subdural  pus  is  present  or  if  the  sinus  itself  is  diseased,  the 
vessel  should  unquestionably  be  uncovered  and  any  diseased  condition 
which  is  found  in  the  vessel  should  be  dealt  with  in  a  surgical  manner. 

The  question  as  to  whether  or  not  the  mastoid  antrum  shall  be 
opened  prior  to  and  as  a  part  of  the  operation  on  the  cerebellum,  must 
be  decided  by  the  amount  of  information  obtainable  concerning  the 
exact  condition  that  is  present  in  the  case,  and  to  some  extent  also  by 
the  physical  condition  of  the  patient  at  the  time  the  operation  is  under- 
taken. If  the  surgeon  can  be  reasonably  positive  that  the  abscess  is 
situated  posterior  to  the  descending  portion  of  the  sinus  and  the  patient's 
strength  is  so  far  wasted  that  prolonged  operating  would  greatly  increase 
the  hazard,  then  there  should  be  no  question  about  the  advisability  of 
primarily  turning  down  the  flap  and  trephining  as  a  primary  measure. 
The  mastoid  operation  can  be  done  at  some  later  period  if  found  neces- 
sary. In  view  of  the  fact,  however,  that  the  original  source  of  the 
infection  is  in  the  mastoid,  if  this  be  not  removed  by  operative  measures, 
the  mastoid  suppuration  will  continue  as  a  menace  to  subsequent  healing 
of  the  adjacent  wounded  structures,  and  may  defeat  the  purpose  of  the 
operation  on  the  abscess,  even  though  the  latter  appear  for  a  time 
entirely  successful.  Moreover,  in  the  extension  of  the  suppurative 
process  backward  from  the  mastoid,  the  lateral  sinus  is  so  frequently 
involved  that  it  should  always  be  closely  scrutinized  and  sometimes 
surgically  dealt  with  at  the  same  time  that  the  cerebellar  abscess  is 
operated;  and  this  can  be  best  done  by  first  opening  and  clearing  away 
the  mastoid  antrum  and  cells.  Finally,  diagnostic  methods  for  deter- 
mining the  presence  of  this  class  of  abscess  are  by  no  means  always 
reliable,  and  what  may  have  previously  seemed  most  certainly  to  be  a 
cerebellar  abscess  may  prove,  at  the  time  of  operation,  to  be  nothing 
more  than  an  extradural  collection  of  pus  in  the  vicinity  of  the  sinus, 
relief  of  which  through  the  performance  of  the  mastoid  operation  and 
exposure'  of  the  sinus  is  all  that  is  surgically  indicated. 

When  the  dura  over  the  site  of  the  abscess  is  sufficiently  exposed 
through  the  removal  of  bone  by  the  trephine  and  forceps,  it  is  first 
examined,  a  flap  of  the  dura  raised,  and  the  cerebellum  is  explored 
exactly  as  in  case  of  examination  of  the  temporosphenoidal  lobe  for  a 
collection  of  pus.  Should,  however,  the  abscess  be  situated  in  the 
anterior  and  deeper  portion  of  the  affected  cerebellar  hemisphere  it  is 
safer  not  to  employ  the  knife  as  the  exploring  instrument,  but  in  its  stead 
the  exploring  trocar  and  canula  should  be  used.  Ballance  (Lancet, 
May,  1901)  recommends  the  use  of  a  canula  having  exterior  rings,  so 
placed  that  when  the  abscess  has  been  penetrated  and  evacuated  by  the 


INTRACRANIAL   COMPLICATIONS  461 

instrument  the  same  may  be  left  in  situ,  serving  as  a  drainage-tube,  which 
may  be  retained  in  place  by  means  of  sutures  passed  through  the  skin 
and  attached  to  the  rings.  This  author  states  that  cases  have  been 
frequently  lost  because  after  the  abscess  has  been  evacuated  the  operator 
fails  to  reintroduce  the  tube  properly  into  the  abscess.  The  suggestion 
as  to  the  method  of  management  given  above,  he  states,  would  if  followed, 
obviate  the  possibilities  of  an  error  of  this  kind. 

The  presence  of  the  abscess  within  the  cerebellum  often  causes 
respiratory  slowing  previously  to  the  operation  for  relief.  During  oper- 
ations upon  the  cerebellum  for  the  relief  of  this  condition,  the  difficulties 
of  respiration  are  sometimes  increased  and  occasionally  the  breathing 
is  altogether  arrested  while  the  heart  action  continues.  The  possibility 
of  arrested  breathing,  therefore,  should  be  borne  in  mind,  the  amount 
of  anesthetic  given  should  be  as  small  as  possible,  and  every  step  of  the 
operation  should  be  as  expeditiously  executed  as  is  consistent  with 
safety  and  thorough  work.  The  after-treatment  of  cerebellar  abscess 
differs  in  no  important  particular  from  that  of  the  cerebral  variety,  which 
has  already  been  described  (see  p.  454). 


CHAPTER  XXXVII 
INTRACRANIAL   COMPLICATIONS    fContinued) 

INFECTIVE    MENINGITIS 

INFLAMMATION  of  the  brain  envelopes,  when  originating  from  a  sup- 
puration within  the  temporal  bone,  is  of  three  varieties — namely, 
pachymeningitis,  leptomeningitis,  and  serous  meningitis.  Tubercular 
meningitis  due  to  an  infection  which  is  secondary  to  tuberculosis  of  the 
ear  is  probably  very  rare. 

Symptoms. — At  the  onset  the  symptoms  of  meningitis  are  often 
ill  denned  and  may  be  identical  with  those  present  at  the  beginning  of 
a  brain  abscess  or  a  lateral  sinus  thrombosis;  and  this  similarity  should 
be  expected,  since  these  latter  diseases  are  in  many  instances  accompanied 
by  a  circumscribed  meningitis  at  the  site  of  the  infection. 

Either  an  acute  or  chronic  discharge  from  the  ear  is  usually  pres- 
ent as  a  symptom.  If  acute,  the  discharge  is  or  has  been  very  profuse 
and  the  entire  aural  affection  has  probably  been  of  unusual  severity. 
Acute  mastoiditis  frequently  accompanies  the  purulent  otitis  media  and 
precedes  the  meningitis.  In  case  the  aural  suppuration  is  chronic  all 
the  symptoms  which  accompany  this  disease  (see  Chapter  XXVII.)  may 
be  present  at  the  onset  of  the  meningitis.  It  should  be  remembered  that 
in  chronic  suppurative  otitis  media  the  aural  discharge  is  sometimes 
very  scant  and  may  not  be  sufficient  to  appear  in  the  external  auditory 
meatus.  In  such  instance  the  patient  may  deny  the  presence  of  aural 
suppuration,  but  this  statement  should  not  deter  a  thorough  physical 
examination  of  the  ears  in  any  case  in  which  the  symptoms  of  meningitis 
are  present. 

Headache  is  the  most  constant  as  well  as  the  most  prominent  symp- 
tom. In  the  developmental  stage  of  the  disease  when  arising  from  an 
aural  infection,  the  headache  is  usually  limited  to  one  side  of  the  head 
and  may  be  designated  by  the  patient  as  consisting  of  only  a  pain  in  and 
around  the  affected  ear.  This  pain,  in  the  majority  of  cases,  however, 
soon  spreads  over  the  whole  head  and  becomes  so  intense  as  to  cause  the 
patient  the  greatest  agony.  The  pain  is  due  to  the  pressure  of  the 
inflammatory  exudate  upon  the  dura,  to  an  increase  of  fluid  within  the 
ventricles,  or  to  an  inflammatory  edema  of  the  brain  substance.  Photo- 

462 


INTRACRANIAL   COMPLICATIONS  463 

phobia  develops  early,  the  patient,  therefore,  turns  from  the  light,  avoids 
conversation,  is  extremely  irritable,  desires  to  be  let  alone,  and  lying  in 
a  room  from  which  all  light  is  excluded  and  with  the  head  held  between 
the  hands,  he  moans  or  cries  aloud  during  the  severest  moments  of  his 
suffering.  Delirium  is  a  frequent  symptom,  especially  in  children,  who 
then  utter  a  peculiar,  piercing  cry,  a  series  of  cries,  or  even  repeat  some 
short  familiar  sentence  in  a  high-pitched  and  most  pitiable  tone  of  voice. 

Convulsions,  or  at  least  convulsive  movements,  may  accompany  the 
delirium.  These  may  amount  only  to  the  twitching  of  certain  muscles 
or  groups  of  muscles  or  may  be  of  an  epileptiform  character.  Rigidity 
of  the  muscles  of  the  posterior  part  of  the  neck  is  characteristic  of  this 
disease;  the  head  is  drawn  backward  and  any  attempt  to  straighten  it 
causes  a  decided  increase  of  the  pain.  In  the  worst  cases,  when  the 
disease  is  well  advanced  and  involves  the  upper  portion  of  the  spinal 
cord,  all  the  muscles  of  the  back  may  be  involved,  and  a  complete 
opisthotonos  may  take  place  and  may  recur  several  times  in  the  twenty- 
four  hours.  Spasm  of  the  muscles  of  the  jaw,  amounting  to  a  condition 
of  trismus,  has  also  been  observed. 

At  the  onset  the  pulse  is  slow  and  the  blood-pressure  high;  but  as  the 
inflammation  of  the  meninges  spreads,  the  heart  action  becomes  rapid 
and  the  blood-pressure  greatly  reduced.  The  temperature  varies  from 
101°  to  106°  F.,  and  is,  therefore,  in  marked  contrast  to  the  temperature 
of  brain  abscess,  in  which  disease  the  temperature  is  subnormal,  normal, 
or  but  very  slightly  elevated.  The  temperature-curve  in  meningitis  also 
differs  from  that  of  sinus  thrombosis,  inasmuch  as  the  remissions  are  not 
so  sudden  or  marked  as  is  the  case  in  infective  thrombosis  of  one  of  the 
large  sinuses. 

Certain  phenomena  connected  with  the  nervous  system  are  also 
observed.  Thus,  hyperesthesia  of  the  entire  integumentary  surface  may 
be  present  to  such  an  extent  that  the  skin  reflexes  are  greatly  exaggerated. 
Vasomotor  paresis  of  the  vessels  of  the  skin  sometimes  takes  place,  as 
can  be  demonstrated  by  drawing  the  finger-nail  or  some  blunt  instru- 
ment firmly  across  its  surface,  in  which  case  a  persisting  white  line  will 
mark  the  site  thus  disturbed.  Among  other  symptoms  of  a  nervous 
origin  may  be  mentioned  herpes  labialis  and  erythematous  eruptions 
upon  the  general  surface  of  the  body. 

The  fundus  of  the  eye  is  frequently  involved.  The  eye-grounds  may 
be  only  congested  or  a  perineuritis  or  choked  disc  may  occur.  The 
views  of  different  observers  vary  greatly  concerning  the  frequency  with 
which  changes  at  the  fundus  of  the  eye  occur  as  a  symptom  of  infective 
meningitis.  Zaufal,  Kneiss,  and  Hansen  state  that  these  changes  are 


464  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

often  observed,  and  they,  therefore,  consider  the  presence  of  an  optic 
neuritis  as  of  great  diagnostic  value.  On  the  other  hand,  Pitt  and 
Korner  found  ocular  changes  only  as  a  rare  objective  symptom  of  this 
disease,  while  Gruening  states  that  optic  neuritis  never  occurs  as  a 
symptom  of  meningitis.  In  31  cases  of  meningitis  reported  by  Tenzier 
(Annals  O.  R.  and  L.,  Vol.  XIV.,  No.  i),  u  or  about  a  third  of  all 
reported  showed  changes  at  the  fundus.  The  conjunctivas,  especially 
should  the  disease  approach  a  fatal  termination,  become  deeply  injected, 
and  showing  between  the  widely  open  lids  the  eyes  present  at  this  time 
a  peculiar  bleared  appearance. 

The  pupils  of  the  eye  are  sometimes  unequal,  sometimes  both  are 
contracted.  Paralysis  of  the  motor  oculi  nerve,  when  occurring, 
results  in  strabismus  or  other  motor  changes  of  the  eyeball,  and  nystag- 
mus is  occasionally  observed. 

Kernig's  sign,  although  demonstrable  in  most  cases,  is  not  conclusive 
evidence  of  the  presence  of  a  meningitis.  The  tendon  reflexes  are  all 
exaggerated. 

Vomiting  is  a  symptom  which  occurs  frequently  in  meningitis,  but 
is  an  indication  of  intracranial  disease  rather  than  of  any  particular 
variety  of  such  disease. 

Constipation  is  the  rule  in  the  beginning  and  throughout  the  greater 
part  of  the  course  of  this  as  of  other  forms  of  meningitis;  but  toward  the 
end  looseness  of  the  bowels  and  involuntary  evacuations  sometimes  occur. 

Diagnosis. — The  diagnosis  can  be  made  only  after  a  full  considera- 
tion of  all  the  symptoms  of  the  patient,  together  with  a  thorough  physical 
examination  of  the  ear  and  of  the  fundus  of  the  eye.  Inspection  of  the 
ear  will  show  the  presence  of  either  an  acute  or  chronic  tympanic  sup- 
puration. In  either  instance  the  pathologic  changes  that  may  be 
present  in  the  auditory  canal,  drum-head,  or  middle  ear  should  be 
determined  with  a  view  of  tracing  the  direct  progress  of  the  infection 
from  the  middle  ear  to  the  meninges.  Any  change  of  structure  that  has 
already  been  described  as  a  possible  outcome  of  aural  suppuration  may 
be  found  present  in  the  ear  during  this  examination  (see  p.  321). 
Lumbar  puncture  is  also  a  valuable  aid  to  the  diagnosis,  not  only  as  to 
the  fact  of  the  presence  of  a  meningitis  but  also  as  to  whether  or  not 
it  is  of  the  serous  or  purulent  variety.  When  employed  as  a  diag- 
nostic measure,  lumbar  puncture  is  made  by  the  method  of  Quincke, 
and  10  or  15  cc.  of  the  spinal  fluid  are  withdrawn  for  the  purpose  of 
inspection,  microscopic  examination,  or  chemical  test.  In  meningitis 
serosa  the  cerebrospinal  fluid  thus  withdrawn  will  be  clear,  whereas  in 
the  purulent  variety  it  is  clouded.  Normal  cerebrospinal  fluid  has 


INTRACRANIAL   COMPLICATIONS 


465 


a  specific  gravity  of  about  i.oio  and  contains  no  albumin  or  at  least 
only  traces.  When  meningitis  is  present  the  specific  gravity  is  higher 
than  normal  and  the  amount  of  albumin  is  greatly  increased.  The 
statement  has  been  made  that  the  presence  of  more  than  i  per  cent,  of 
albumin  in  the  spinal  fluid  is  positively  indicative  of  a  meningitis;  and 
should  the  microscopic  examination  of  the  fluid  in  such  a  case  show  the 
presence  of  pus  and  an  increase  of  polymorphonuclear  cells,  the  diagnosis 
of  meningitis  can  be  positively  made. 

DIFFERENTIAL    DIAGNOSIS  IN  UNCOMPLICATED   INTRACRANIAL   DIS- 
EASES  OCCURRING  AS  THE  RESULT  OF  AURAL  SUPPURATION 


Meningitis 


Sinus  Thrombosis 


Brain  Abscess 


Aural  discharge.  Either     present     now      or     Present  or  has  been  present.     Present  or  has  been  present, 

there  are  found  on  physi- 
cal examination  of  the 
ear  evidences  of  former 
suppuration. 

Temperature.  Sometimes     high,     usually     Nearly    always   high    with     May  be  at  first  elevated, 

moderate,  and  remissions        decided  remission.      Of-        soon    falls    to    near    the 


Pulse. 


Pain. 


gradual. 


ten  suddenly  rises,  then 
markedly  drops.  Re- 
missions may  occur  more 
than  once  in  twenty-four 
hours. 


normal,  normal,  or  even 
subnormal.  Remains 
low  throughout  unless 
abscess  ruptures  and 
meningitis  develops  as  a 
complication. 


Greatly  accelerated.  Rapid  and  often  small  and    Accelerated  at  first,  is  later 

weak.  normal     or     abnormally 

slow  and  full.  Becomes 
weak  and  rapid  if  ab- 
scess ruptures  and  death 
approaches. 


Always  present  in  form  of     Seldom  diffused  over  whole    Usually  present,  at  first  in 
headache;    severest   over        head.     Not  always  pres-         the  ear  or  over  mastoid; 
ent,  but  when  so,   is  lo- 
cated in  ear,  over  mastoid 
or  along  neck  of  affected 
side. 


forehead,  but  extends  to 
all  parts  of  the  head. 
Pain  in  the  neck,  which 
is  stiff  and  immovable. 


later  localizes  over  tem- 
poral or  frontal  region 
of  same  side.  Usually 
persistent  and  severe, 
and  may  be  remote  from 
seat  of  abscess. 


Chill. 


Sweating. 


Vomiting. 


Respiration. 


Chilly     sensations     or     a     Chill    or    chilly   sensations     Not  frequent   nor   charac- 
marked  chill  may  occur        frequent  throughout  dis-        teristic. 
ease.      Sometimes  occur 
more      than      once      in 
twenty-four  hours.    Very 
severe  and  characteristic 
during   disintegration  of 
clot. 


at  onset,  but  are  not  fre- 
quent or  characteristic 
during  later  stages. 


Seldom  occurs  and  is  not  a     Occurs  frequently;  is   pro-    Seldom  present.     Not  dis- 
diagnostic  feature.  fuse  and  exhaustive,  and        tmctive. 

is  very  characteristic  in 
typic  cases. 

Nearly  always  occurs  dur-     Seldom  present;  not  char-     Frequently     present,     per- 
ing   some   stage    of    the        acteristic.  sistent,  and  "cerebral, 

progress  of  the  disease, 
is  of  "cerebral"  type, 
and  independent  of  in- 
gestion  of  food. 


Rapid,   and   in   proportion  Not  markedly  affected,  un-     Slow     and     full. 

to    the    acceleration    of  less   lungs   are   involved        pressure  ^of  ^a 

pulse  and  rise  in    tern-  by  septic  pneumonia, 
perature. 


When 
:ess    is 

considerable  the  breath- 
ing may  become  ster- 
torous. 


30 


466 


THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


Kfeningiiis 


Sinus  Thrombosis 


Muscular 
disturbances. 


Mentality. 


Eye  symptoms. 


Kernig's  sign. 
Paralysis. 


Course  and 
termination. 


Stiffening  of  the  muscles  of  Very  seldom  occur, 
the  back  of  the  neck 
usually  occurs.  The 
head  is  retracted  and 
somewhat  fixed.  Rigid- 
ity of  muscles  of  abdomen 
and  back  occur  and 
sometimes  general  con- 
vulsions are  present. 

Unimpaired  except  by  pain.     Unimpaired  except  in  pro- 


Patient irritable  and  de- 
sires to  be  let  alone. 
Later  stages,  mentality 
may  be  greatly  impaired 
or  lost. 


longed  cases  and  toward 
a  fatal  termination. 


Perineuritis,  congestion,  or     Perineuritis,    choked    disc, 
choked   disc  present   in         etc.,  occur  in  about  one- 
about    one-third    of    all         fourth  of  all  cases, 
cases.        Contracted     or 
unequal  pupils  frequent. 
Photophobia  almost  con- 
stantly present. 

Demonstrable  in  80  to  oo     Not  present, 
per  cent,  of  cases. 


Infrequent   until    late. 


Leptomeningitis  usually 
runs  a  rapid  course. 
The  patient  at  once 
prostrated  and  appears 
seriously  ill.  Death  may 
occur  in  three  days,  but 
sometimes  is  delayed  two 
or  three  weeks. 


Not  often  present. 


Usually  severe  and  rapid, 
with  symptoms  of  ex- 
treme exhaustion.  Oc- 
casionally terminates  in 
resolution  and  recovery. 
Death  occurs  from  sep- 
tic pneumonia  or  met- 
astatic  abscess  of  brain, 
lung,  liver,  or  extremities. 


Brain  Abscess 

Convulsions    rarely    occur. 
Stiffness  of  neck  absent. 


Sometimes  unimpaired  even 
when  large  abscess  is 
present.  More  fre- 
quently mental  processes 
are  slow  and  typhoid  in 
character. 

Optic  neuritis  frequent  in 
later  stages.  Inequality 
of  pupils  and  photo- 
phobia sometimes  pres- 
ent 


Not  present. 


Paralysis  of  ocular  mus- 
cles frequent.  Where 
abscess  is  large,  arm  and 
leg  of  opposite  side  may 
be  involved.  If  on  the 
left  side  speech  center 
may  be  implicated,  apha- 
sia resulting. 

May  be  of  short  duration  if 
acute.  Chronic  abscess 
may  be  "latent,"  encap- 
sulated, and  continue 
for  months  or  years. 
Death  occurs  from  rup- 
ture of  abscess  into  brain 
with  resulting  meningitis. 


Prognosis. — A  majority  of  all  cases  of  circumscribed  meningitis 
recover,  provided  the  radical  mastoid  operation  is  performed  and  the 
accompanying  epidural  abscess  is  evacuated  before  the  infection  spreads 
and  results  in  a  general  purulent  meningitis.  This  latter  disease  is  almost 
certainly  a  fatal  one,  only  a  few  instances  of  recovery  having  as  yet  been 
recorded  as  a  result  of  treatment  by  lumbar  puncture  and  subdural 
drainage.  Serous  meningitis  is,  however,  a  much  more  hopeful  affection, 
and  a  majority  recover  following  the  prompt  removal  of  the  septic 
foci  from  the  temporal  bone  and  the  relief  of  the  intracranial  pressure 
by  means  of  lumbar  puncture. 

Treatment. — The  treatment  of  infective  meningitis  depends  upon 
the  extent  and  character  of  the  disease.  In  case  the  diagnosis  of  a 
localized  external  pachymeningitis  is  made,  the  radical  mastoid  operation 
should  be  performed  as  early  as  the  symptoms  of  the  extension  of  the 
septic  inflammation  to  the  dura  is  discovered.  Such  a  circumscribed 
inflammation  of  the  dura  frequently  occurs  in  long-standing  cases  of 
aural  suppuration  over  the  tegmen  antri  or  tegmen  tympani  above, 
or  in  the  region  of  the  sigmoid  groove  posteriorly,  and  in  either  of  these 


INTRACRANIAL   COMPLICATIONS  467 

situations  it  is  frequently  associated  with  an  extradural  collection  of 
pus.  When  the  dura  is  sufficiently  laid  bare  during  the  mastoid  opera- 
tion by  the  removal  of  the  underlying  bone  and  free  drainage  is  thereby 
secured  and  maintained  until  the  healing  takes  place,  recovery  is  the 
rule  provided  the  operation  has  been  done  before  the  pus  has  burrowed 
through  the  dura  and  set  up  an  internal  pachymeningitis  or  before  it 
has  ruptured  into  the  arachnoid  space  and  has  resulted  in  a  purulent 
leptomeningitis.  These  latter  varieties  prove  fatal  almost  without 
exception  under  any  form  of  treatment.  When  the  meningitis  has  once 
spread  and  has  become  general,  free  exposure  and  incision  of  the  dura 
is  indicated  and  furnishes  the  most  hopeful  means  of  treatment,  but 
even  surgical  measures  have  as  yet  met  with  little  encouragement  in 
the  way  of  favorable  results. 

The  technic  of  the  operation  best  suited  for  all  forms  of  general 
meningitis  consists  in  turning  back  a  flap  of  the  soft  tissues  about  i 
inch  above  and  behind  the  affected  ear,  of  trephining  the  skull  at  this 
point,  and  of  enlarging  the  trephine  opening  by  means  of  bone  forceps. 
All  extradural  collections  of  pus  which  may  be  found  upon  exposing 
the  dura  should  be  washed  away  by  a  gentle  stream  of  hot  boric  acid  or 
normal  salt  solution,  after  which  a  blunt  spatula  may  be  used  to  separate 
the  dura  from  the  adjoining  skull  and  press  it  away  from  the  inner 
table;  at  the  same  time  the  patient's  head  is  held  in  a  lowered  position 
in  order  to  favor  the  outflow  of  pus  or  other  exudate  from  every  direction 
in  the  vicinity  of  the  wound.  After  thus  cleansing  as  broad  an  area  of 
the  dura  as  possible,  a  flap  should  be  cut  from  the  dura,  the  convolutions 
of  the  brain  should  be  gently  lifted  by  the  spatula,  boric  solution  may  be 
used  for  irrigation,  and  finally  a  sterile  gauze  wick  or  a  cigarette  drain 
should  be  placed  through  the  opening  in  the  dura  and  brought  out  at 
the  lower  angle  of  the  flap.  The  skin  flap,  including  all  the  extra 
cranial  soft  tissues,  is  finally  sutured  in  place,  leaving,  of  course,  an 
opening  at  its  lower  angle  through  which  the  gauze  drain  emerges. 
A  large  quantity  of  loose  gauze  should  then  be  placed  over  the  site  of 
the  external  wound  for  the  purpose  of  catching  the  serum  which  sub- 
sequently exudes,  and  this  should  in  turn  be  covered  by  cotton,  rubber 
protective,  and  finally  by  a  roller  bandage. 

The  patient  should  subsequently  lie  in  such  a  position  as  to  favor 
the  drainage,  which  in  most  instances  is  very  profuse.  When  the 
dressings  become  saturated  from  the  discharge  a  change  of  the  outer 
portion  should  be  made,  but  the  gauze  wick  leading  through  the  incision 
in  the  dura  must  be  left  undisturbed  so  long  as  it  is  thought  necessary 
to  continue  this  mode  of  treatment.  The  gauze  will,  however,  be 


468 


pushed  out  as  rapidly  as  the  wound  fills  with  granulations,  provided, 
of  course,  subsidence  of  the  inflammation  occurs  and  a  subsequent 
cure  takes  place. 

Lumbar  puncture  has  been  tried  in  leptomeningitis,  both  by  itself 
and  in  conjunction  with  subdural  drainage,  but  aside  from  its  diagnostic 
assistance  this  measure  has  proved  of  but  little  permanent  benefit.  In 
the  treatment  of  serous  meningitis,  however,  lumbar  puncture  is  of 
great  value,  should  be  early  performed,  and  as  much  as  25  to  100  cc. 
of  the  clear  fluid  be  thus  removed.  The  lumbar  puncture  and  aspiration 
of  fluid  may  be  repeated  one  or  more  times,  after  which,  if  marked 
improvement  or  recovery  does  not  promptly  take  place,  drainage  through 


TIG.  280. — NEEDLE  FOR  WITHDRAWING 
SPINAL  FLUID  (KRONIG). 


FIG.   281. — LUMBAR    PUNCTURE   (SCHEMATIC),     i,    Paracentesis 
needle;  2  to  5,  second  to  sixth  lumbar  vertebra;  (Briihl-Politzer). 


the  dura  may  be  established  according  to  the  method  just  described  in 
the  treatment  of  leptomeningitis. 

Since  lumbar  puncture  according  to  the  method  of  Quincke  is  now 
frequently  employed  to  secure  a  specimen  of  the  cerebrospinal  fluid  for 
microscopic  or  chemical  examination,  as  an  aid  to  diagnosis,  or  as  a 
means  of  treatment  of  serous  meningitis,  Meniere's  disease,  etc.,  a 
brief  description  of  the  method  of  its  performance  is  essential:  The 
puncture  is  made  and  withdrawal  of  the  spinal  fluid  is  accomplished 
by  means  of  a  sharp,  stout  hollow  needle  (Fig.  280).  The  point  selected 
for  the  insertion  of  the  needle  is  between  the  third  and  fourth  lumbar 
vertebra.  The  skin  of  the  adjacent  area  having  been  thoroughly 


INTRACRANIAL   COMPLICATIONS  469 

sterilized  and  the  needle  freshly  boiled  and  immersed  in  alcohol,  the 
point  of  the  instrument  is  entered  at  a  distance  of  about  i  inch  to  one 
or  the  other  side  of  the  spinous  process  of  the  third  lumbar  vertebra, 
at  which  point  it  is  thrust  in  a  direction  that  will  insure  its  entrance 
into  the  dural  sac  under  this  spine  and  exactly  in  the  median  line  (Fig. 
281).  Lumbar  puncture  is  not  a  painful  operation  if  skilfully  performed 
and  anesthesia  of  the  part  is,  therefore,  usually  not  necessary.  How- 
ever, in  the  case  of  very  sensitive  individuals  a  10  per  cent,  solution  of 
phenol  in  glycerin  should  be  applied  to  the  area  of  skin  to  be  punctured, 
and  this  will  to  some  extent  render  the  skin — the  most  sensitive  part — 
somewhat  anesthetic. 


CHAPTER    XXXVIII 

SUPPURATION  AND  NECROSIS  OF  THE  TEMPORAL 
BONE  AND  ITS  PRACTICAL  RELATION  TO  LIFE 
INSURANCE 

To  the  life  insurance  examining  surgeon  the  vital  question  con- 
cerning the  applicant  will  always  be,  Is  the  risk  safe?  In  so  far  as 
known  to  the  author,  no  company  of  prominence  omits  in  any  case  to 
investigate  both  the  present  and  past  condition  of  the  applicant's  ears. 
It  must  be,  therefore,  that  life  insurance  companies  have  recognized  the 
full  importance  of  such  investigation,  and  have  accepted  as  a  fact  that 
actual  dangers  to  life  lurk  in  every  discharging  ear — dangers  equally 
as  grave  as  those  which  may  be  found  in  the  urinary,  circulatory,  or 
nervous  system,  or  in  the  faulty  habits  of  the  applicant  for  life  insurance. 

The  insurance  company  justly  expects  that  the  examining  surgeon 
will  discover  the  weakness  and  dangers,  if  any  exist,  of  all  applicants 
for  life  insurance.  The  deep-seated  situation  of  the  ear  and  conse- 
quently the  difficulties  attendant  upon  the  efforts  to  obtain  accurate 
knowledge  concerning  any  aural  affection,  are  responsible  for  frequent 
errors  on  the  part  of  the  examiner  in  advising  the  acceptance  of  non- 
insurable  applicants;  or,  on  the  other  hand,  in  rejecting  those  in  whom 
it  is  merely  surmised  that  some  serious  aural  ailment  is  present,  when,  in 
fact,  only  the  most  trivial  disease  exists  and  when  the  applicant  is 
undoubtedly  a  safely  insurable  one. 

The  chief  points  relating  to  this  subject  may  be  briefly  stated  in 
answering  the  three  following  questions: 

i.  What  symptoms  given  by  the  patient  and  what  pathologic  con- 
ditions found  in  the  diseased  ear  by  the  examining  surgeon  should  be 
regarded  as  sufficiently  dangerous  to  justify  the  rejection  of  the  applicant  ? 

The  author  believes  that  no  just  decision  can  be  made  as  to  whether 
any  applicant  is  or  is  not  insurable,  unless  the  examiner  takes  into 
consideration  not  only  the  symptoms  stated  by  the  patient  himself 
but  also  the  more  reliable  facts  which  he  is  able  to  obtain  from  a  most 
thorough,  painstaking,  and  accurate  examination  of  the  condition  of 
the  middle  ear  and  its  accessory  cavities.  It  is  the  duty  of  the  examining 
surgeon  to  make  such  an  examination  of  every  applicant  who  states 

470 


SUPPURATION   AND   NECROSIS   OF   THE   TEMPORAL   BONE  471 

that  he  has  once  had  a  discharging  ear,  for  it  is  a  noteworthy  fact  that 
most  extensive  destruction  of  the  soft  structures  of  the  ear  and  of  the 
adjoining  osseous  structures  of  the  temporal  bone  may  take  place 
during  a  prolonged  suppuration  within  the  tympanic  cavity,  without 
the  individual  ever  making  any  sort  of  complaint  as  to  pain  or  other 
discomfort.  Neither  is  there  present  in  many  cases  any  evidence 
superficially  to  indicate  the  dangerous  and  hidden  process  which  is 
going  on  within.  Cases  of  suppurative  middle-ear  disease  have  been 
reported  in  which  the  individuals  followed  their  usual  occupation  up  to 
the  very  hour  of  the  rupture  of  a  brain  abscess,  due  to  extension  of  the 
suppurative  process  from  the  ear,  and  the  author  has  reported  a  case 
in  which  the  patient  was  in  school,  making  his  grades,  for  many  months 
during  a  time  when  the  right  temporosphenoidal  lobe  of  the  brain  was 
largely  filled  by  an  otitic  abscess.  It  must,  therefore,  be  conceded 
that  there  are  non-insurable  applicants  who  may  present  symptomless 
records  with  the  exception  of  a  discharging  ear;  and  the  presence  of 
this  symptom  is  often  lightly  regarded  or  even  honestly  denied  by  the 
applicant. 

If  an  applicant  with  an  aural  discharge,  however  slight,  or  with 
the  history  of  having  had  at  one  time  an  aural  suppuration,  should  also 
be  found  to  suffer  from  headache,  occasional  and  unaccountable  fits 
of  irritableness  of  disposition  or  of  dizziness,  such  group  of  symptoms 
would  undoubtedly  lessen  the  degree  of  safety  of  the  risk.  Headache 
on  the  same  side  of  the  head  as  the  affected  ear  is  an  early  and  most 
constant  symptom  of  brain  extension,  and  should  never  fail  to  be  given 
proper  significance.  This  headache  is  usually  not  in  the  immediate 
vicinity  of  the  diseased  ear  and,  therefore,  unless  the  examining  surgeon 
is  alert  to  the  possible  import  of  this  important,  early,  and  almost  constant 
symptom  of  brain  involvement,  he  may  in  no  way  connect  the  aural 
suppuration  with  it.  In  this  class  of  cases,  therefore,  the  subjective 
symptoms  of  aural  suppuration  are  of  very  greatly  less  value  to  the 
examiner  than  is  the  information  which  may  be  obtained  by  the  most 
searching  examination  of  every  part  of  the  ear  itself  and  of  the  open 
cavities  of  the  temporal  bone,  provided,  of  course,  that  the  surgeon 
skilfully  uses  every  known  and  modern  otologic  method  in  his  inves- 
tigation. 

If  the  middle  ear  or  its  accessory  cavities,  the  mastoid  antrum  or 
mastoid  cells,  contain  diseased  and  polypoid  mucous  membrane;  if 
the  mucous  membrane  is  wanting  in  places,  leaving  the  underlying  bone 
bare;  if  the  bony  structures  are  carious  or  sequestered,  abundant  ex- 
perience has  shown  that  the  suppurative  process  is  a  progressive  one, 


472  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

and  that,  unless  checked  by  surgical  interference,  it  is  apt  to  result 
ultimately  in  some  intracranial  complication  and  premature  death. 
In  long-standing  suppuration,  where  the  perforation  of  the  drum  mem- 
brane is  of  considerable  size,  the  epithelium  of  the  skin  of  the  external 
auditory  meatus  is  apt  to  grow  through  the  opening  and  into  the  attic 
and  antrum,  where  there  is  an  accumulation  of  those  curious  and  dan- 
gerous masses  known  as  cholesteatoma.  In  the  author's  opinion  no 
case  of  cholesteatomatous  ear  should  ever  be  considered  a  safe  risk, 
because  both  operative  interferences  for  the  cure  of  intracranial  com- 
plication and  post-mortem  examination  of  the  cranial  contents  of 
those  who  have  died  as  the  result  of  aural  suppuration  have  shown  the 
presence  of  cholesteatoma  as  a  causative  factor  of  the  death  in  a  large 
proportion  of  cases. 

If  in  any  case  of  aural  suppuration  the  external  auditory  meatus 
should  be  occluded  to  any  considerable  degree  as  a  result  of  chronic 
eczematous  thickening  of  the  skin,  osteoma  of  the  bony  canal,  or  by 
the  presence  of  a  foreign  body,  the  individual  should  be  considered 
unfit  for  insurance.  If  one  or  more  fistulae  exist  in  the  external  auditory 
canal  or  over  the  mastoid  surface,  the  risk  should,  without  question, 
be  regarded  an  unsafe  one,  because  such  fistulae  always  lead  into  the 
depths  of  the  temporal  bone,  where  there  are  in  progress  necrotic  proc- 
esses which  are  highly  dangerous  to  the  life  of  the  individual. 

2.  In  what  class  of  discharging  ear,  if  any,  is  an  individual  safely 
insurable,  and  what  symptoms  are  indicative  of  the  fact  ?  Also,  What 
pathologic  conditions  may  be  present  in  a  discharging  ear  without 
serious  danger  to  the  life  of  the  applicant? 

Without  question,  there  are  many  suppurating  ears  which  are  apt 
to  continue  indefinitely  without  serious  risk  to  the  life  of  the  individual; 
or,  at  least,  the  risk  is  so  small  that  the  examining  surgeon,  could  he 
know  the  exact  pathology,  would  not  hesitate  to  recommend  the  accept- 
ance of  the  case.  Unfortunately  no  intelligent  subjective  symptom 
or  group  of  symptoms  indicative  of  either  the  innocence  or  danger  of 
the  discharge  are  present  in  such  cases,  and,  therefore,  the  deep  cavities 
of  the  middle  ear  must  be  thoroughly  inspected  and  the  nature  of  every 
condition  which  is  found  to  be  present  must  be  interpreted  by  an  ex- 
perienced aurist  before  it  should  be  said  that  any  given  case  of  otorrhea 
is  safely  insurable.  Briefly  stated,  if  the  following  conditions  exist, 
the  case  is  one  of  minimum  risk :  (a).  Cause  of  discharge  primarily  due 
to  catarrhal  conditions  of  nose  or  nasopharynx,  and  not  the  result  of 
violent  infection  from  scarlet  fever,  la  grippe,  or  diphtheria.  (&)  The 
character  of  the  discharge  mucopurulent  and  free  from  blood  or  odor; 


SUPPURATION   AND    NECROSIS    OF   THE   TEMPORAL    BONE  473 

or  if  pungent  odor  is  present  it  may  be  readily  checked  by  antiseptic 
cleansing,  (c)  A  perforation  in  the  lower  half  of  the  drum  membrane 
which  is  of  sufficient  size  to  insure  efficient  drainage,  (d)  Entire 
absence  of  caries,  or  necrosis  of  ossicles,  or  of  bone  in  the  middle  ear  or 
antrum,  and  also  of  exuberant  or  necrotic  granulations.  The  existence 
of  the  above  conditions  should  be  ascertained  by  actual  examination, 
and  not  by  inference  or  conjecture,  before  recommendation  for  accept- 
ance is  made. 

3.  What  class  of  case  may  be  safely  insurable  after  local  treatment  or 
after  the  employment  of  some  surgical  procedure  instituted  for  a  cure  ? 

In  the  present  highly  developed  state  of  the  otologic  science  it  may 
be  stated  that  there  are  but  comparatively  few  discharging  ears  that 
cannot  be  cured,  and  the  patient,  therefore,  become  an  entirely  safe  risk 
in  so  far  as  the  aural  disease  is  concerned.  The  presence  of  tubercle, 
advanced  syphilis,  or  cancer  of  the  ear  is  here,  as  elsewhere,  often  beyond 
the  help  of  the  surgeon,  and,  therefore,  furnishes  an  exception  to  the 
above  statement.  The  well-trained  aurist  of  to-day  views  a  discharging 
ear  from  the  same  standpoint  as  does  the  general  surgeon  any  case  which 
is  put  before  him.  He  asks  why  an  ear  discharges  and  has  continued  to 
discharge  and  does  not  consider  himself  competent  to  attempt  treatment 
until  he  has  ascertained  the  cause.  If  the  "why"  is  found  to  be  only 
a  lack  of  aural  cleanliness,  the  cure  is  easy  and  the  risk  safe.  If  adenoids 
or  nasal  obstruction  be  the  cause,  the  remedy  is  at  hand,  is  certain  of 
results,  and  again  the  risk  is  good ;  if  a  dead  ossicle  is  acting  as  a  foreign 
body  in  the  ear,  setting  up  granulation,  polypi,  or  bloody  discharge,  no 
surgical  procedure  could  be  more  sensible  than  its  removal,  for  cure  will 
certainly  follow  and,  therefore,  the  patient  will  become  safely  insurable. 
Again,  if  examination  has  made  certain  the  fact  of  extensive  denudation 
of  bone  in  the  tympanic  cavity  and  consequent  caries  or  necrosis;  or,  if 
the  formation  of  cholesteatoma  is  determined,  the  radical  mastoid 
operation  is  of  such  far-reaching  nature  that  it  can  be  made  to  include 
the  removal  of  almost  any  tissue  that  is  liable  to  disease  from  a  suppura- 
tive  process  within  the  temporal  bone,  and  when  properly  performed 
and  when  skilful  after-attention  is  given  until  the  parts  are  thoroughly 
healed,  the  procedure  will  undoubtedly  render  the  individual  safely 
insurable.  It  should  not,  however,  be  understood  that  solely  because 
an  ear  patient  has  had  an  ossiculectomy  or  a  radical  mastoid  operation 
performed  that,  therefore,  such  individual  is  cured  and  has  become  a 
good  risk.  The  pertinent  question  in  each  such  case  which  the  examining 
surgeon  should  ask  himself,  and  be  certain  to  ascertain,  ought  to  be: 
"Has  the  operating  surgeon  completely  removed  the  diseased  tissue 


474  THE   PRINCIPLES   AND    PRACTICE   OF   OTOLOGY 

which  formerly  caused  the  discharge,  has  the  operative  wound  satis- 
factorily healed,  and  has  the  aural  discharge  ceased  ?"  Because  in  aural 
surgery  perhaps  more  than  elsewhere  the  operation  which  removes  all 
the  diseased  parts  will  usually  cure,  whereas  the  operation  which  fails 
in  thoroughness  fails  to  cure.  In  general  it  may  be  said,  however,  that 
if  after  a  surgical  operation  which  is  instituted  for  the  cure  of  a  discharg- 
ing ear,  that  when  the  ear  has  remained  dry  and  free  from  accumulation 
for  a  period  of  six  months  preceding  the  time  of  the  application  for 
insurance,  the  risk  may  be  considered  safe. 


CHAPTER    XXXIX 
CHRONIC   NON-SUPPURATIVE   OTITIS   MEDIA 

Preliminary  Statements. — Chronic  non-suppurative  otitis  media 
is  usually  described  consecutively  to  the  several  varieties  of  acute  inflam- 
mation of  the  middle  ear.  Such  an  arrangement  breaks  the  continuity 
in  the  description  of  the  natural  subsequent  history  of  the  acute 
inflammatory  diseases  of  the  tympanum,  and  since  this  history  often 
begins  in  a  simple  catarrhal  otitis  media,  passes  through  the  stages  of 
acute  and  chronic  suppuration,  and  ends  in  some  complicating  aural 
ailment,  as  acute  or  chronic  mastoiditis  or  an  intracranial  involvement, 
it  has  seemed  wisest  to  continue  the  description  of  all  the  suppurative 
aural  diseases  to  the  end  without  interruption.  Should,  therefore,  this 
present  classification  appear  to  be  an  unnatural  one  when  viewed  from 
the  standpoint  of  pathology,  it  is  an  entirely  justifiable  one  when  con- 
sidered in  the  interest  of  the  student,  who  is  best  served  by  an  unbroken 
study  of  all  the  pyogenic  aural  affections. 

The  above  title  is  intended  to  include  the  various  forms  of  aural 
disease  which  have  been  described  by  different  writers  under  the  names 
of  "Chronic  Middle-ear  Catarrh,"  "Dry  Middle-ear  Catarrh,"  "Adhe- 
sive Catarrh  of  the  Middle  Ear,"  and  "Hyperplastic  Middle-ear 
Catarrh." 

The  affection  usually  has  its  beginning  in  an  acute  exudative  catarrh 
of  the  middle  ear  which  for  some  reason  fails  to  undergo  those  processes 
of  resolution  necessary  for  restoration  to  the  normal,  and  continues  into 
an  indefinitely  chronic  state  in  which  hypertrophy  first  occurs  and,  later, 
true  hyperplasia  of  the  structures  of  the  middle  ear  takes  place. 

This  disease,  therefore,  when  once  its  natural  tendency  toward  the 
deposit  of  new  tissue  within  the  cavity  of  the  tympanum  has  been 
accomplished,  forms  one  of  the  most  difficult  aural  problems,  in  so  far 
as  relief  or  cure  of  the  ailment  is  concerned.  Many  patients  afflicted 
with  this  variety  of  aural  affection  represent  a  condition  of  neglect  on  the 
part  of  those  who  had  charge  of  the  bringing  up  of  the  individual  during 
childhood;  for  although  most  of  this  class  of  patients  are  incurable  after 
the  disease  has  persisted  into  adult  life,  there  was  a  time  in  the  history 
of  most  of  those  who  suffer  from  chronic  catarrhal  otitis  media  when 

475 


476  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

treatment,  properly  directed  toward  the  relief  of  pathologic  conditions 
existing  in  the  upper  air  tract  of  the  child,  together  with  proper  attention 
to  the  Eustachian  tube  and  middle  ear,  would  have  either  cured  or 
greatly  modified  the  subsequent  aural  disease.  One  of  the  greatest 
avenues  open  to  the  future  progress  of  otology  lies  in  the  direction  of 
prevention  rather  than  the  cure  of  this  common,  but  intractable  aural 
disease.  One  of  the  unpleasant  duties  of  the  aurist  is  to  dismiss  daily 
one  or  more  of  these  patients  after  a  careful  examination  has  shown  the 
hopeless  nature  of  the  case,  with  an  unfavorable  prognosis,  and  the 
statement  that  treatment  will  probably  accomplish  little  or  nothing 
in  the  way  of  relief  or  cure.  On  such  occasions  the  otologist  misses  an 
opportunity  for  doing  future  good  if  he  neglects  to  state  to  these  incur- 
able patients  that  should  they  have  children  or  grandchildren  who  are 
just  beginning  to  develop  an  aural  ailment  they  should  not  be  per- 
suaded into  the  error  of  letting  them  "outgrow  it." 

Pathology. — Chronic  catarrhal  otitis  media  is  caused  by  naso- 
pharyngeal  diseases,  such  as  hypertrophy,  atrophy,  hyperplasia  of 
adenoid  tissue,  and  ulcerations.  Chronic  catarrh  of  the  Eustachian 
tube  may  extend  to  the  middle  ear,  or  acute  catarrh,  after  five  or  six 
weeks'  duration,  is  called  chronic  catarrh.  Constitutional  conditions, 
anemia,  diabetes,  and  general  diseases,  such  as  tuberculosis  and  syphilis, 
favor  chronic  catarrh. 

In  the  middle  ear  there  is  the  formation  of  a  non-suppurative  in- 
flammatory exudate,  with  deposit  of  new  tissue  and  consequently 
resulting  in  changes  in  the  mucous  membrane.  The  exudate  is  a 
mixture  of  exudate  and  transudate;  the  exudate  resulting  from  inflam- 
matory changes,  the  transudate  from  the  closure  of  the  Eustachian  tube, 
as  explained  under  the  chapter  on  Acute  Catarrh  of  the  Middle  Ear. 
From  the  growth  of  a  new  tissue  and  the  collection  of  exudate  plus 
transudate  two  forms  of  catarrh  are  distinguished:  the  hypertrophic 
and  the  exudative.  These  two  forms  cannot  be  easily  separated  and 
blend  into  each  other  like  colors  of  the  rainbow.  The  mucous  mem- 
brane may  be  very  slightly  swollen  or  so  much  thickened  as  to  completely 
fill  the  tympanic  cavity.  In  this  latter  condition  the  mucosa  resembles 
the  embryonic  cushion  found  in  the  middle  ear  of  the  infant  at  birth. 
Instead  of  affecting  all  parts  of  the  mucosa  equally  the  swelling  may 
be  limited  to  certain  parts;  thus,  the  windows  of  the  labyrinth  or  only 
the  mucosa  around  the  Eustachian  tube  may  be  affected.  The  exudate 
is  sometimes  serous  and  again  of  mucoid  consistency.  The  disease 
may  stop  in  time  for  reparative  processes  to  take  place  or  it  may  go  on 
to  atrophy  of  the  mucous  membrane.  Adhesions  may  have  formed 


CHRONIC   NON-SUPPURATIVE   OTITIS   MEDIA  477 

and  these  sometimes  cause  complete  rigidity  of  the  ossicles.  Chalky 
deposits  may  be  found  in  the  mucous  membrane,  membrana  tympani, 
and  tympanic  cavity;  especially  in  the  membrane  of  the  cochlear  window 
and  in  the  drum  membrane. 

Causation. — Probably  the  most  frequent  cause  of  this  disease  is 
previous  and  frequently  repeated  attacks  of  acute  catarrhal  otitis 
media;  and  it  has  already  been  pointed  out  that  the  acute  affection 
usually  depends  in  a  great  measure  upon  a  diseased  condition  of  the 
nose  and  nasopharynx,  chiefly  in  the  form  of  adenoids,  enlarged  faucial 
tonsils,  or  a  chronic  nasopharyngitis.  Chronic  adhesive  middle-ear 
catarrh  may,  therefore,  be  frequently  traced  to  a  diseased  state  of  the 
upper  air  tract  which  was  allowed  to  go  untreated  until  late  childhood 
or  perhaps  was  not  treated  at  all,  with  the  result  that  frequent  tubo- 
tympanic  aural  congestion  occurred,  the  formation  of  exudates  in  the 
middle  ear  took  place,  and  ultimately  there  was  a  deposit  of  connective 
tissue  upon  the  tympanic  membrane,  about  the  ossicular  articulations, 
and — most  harmful  of  all — in  the  pelvis  ovalis  and  upon  the  foot-plate 
of. the  stapes. 

Other  causes  are  usually  only  secondary  to  the  one  already  men- 
tioned. Thus,  heredity  is  assigned  by  many  as  a  leading  factor  in  the 
production  of  this  affection,  and  without  question  many  instances  may 
be  cited  of  the  disease  attacking  different  members  of  the  same  family 
and  for  several  generations.1 

It  is  also  true  that  tendencies  toward  lymphatic  enlargement  are 
equally  frequent  in  different  members  of  the  same  family,  and  through 
several  generations,  and  whereas  such  lymphoid  hypertrophy  is  not 
always  boldly  in  evidence  in  every  case  of  chronic  catarrhal  disease, 
yet  if  careful  examination  of  the  nasopharynx  be  made  in  every  instance 
of  chronic  catarrhal  otitis  media,  it  will  be  seen  that  a  patch  of  adenoid 
tissue  exists  in  the  vault  of  a  vast  majority  of  all,  and  certainly  a  large 
enough  percentage  of  cases,  to  establish  the  very  frequent  causative 
relationship  of  the  one  to  the  other  disease. 

Patients  are,  however,  seen  in  whom  the  most  careful  examination 
of  the  upper  air  tract  will  furnish  no  reasonable  explanation  for  the 

1  It  is  highly  probable  that  many  of  these  cases  in  which  heredity  seems  to  be  the 
chief  factor  in  the  causation  of  this  disease,  that  the  ailment  is  really  an  otosclerosis  and 
not  a  dry  middle-ear  catarrh.  Politzer  has  expressed  the  opinion  that  the  particular 
form  of  progressive  deafness  which  runs  its  course  from  its  very  incipiency  without  visible 
evidence  of  catarrhal  symptoms  should  be  regarded  as  essentially  different  from  aural 
affections  in  which  the  adhesive  process  is  secondary  to  some  catarrhal  state.  In  other 
words,  those  cases  occurring  independently  of  inflammatory  states  in  the  nose,  nasopharynx, 
and  Eustachian  tube  should,  more  properly,  be  classed  under  otosclerosis  (see  p.  511). 


478  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

existence  of  the  aural  affection.  In  cases  like  this,  and  in  those  in 
whose  family  there  is  a  history  of  this  particular  aural  disease,  the 
causation  may  no  doubt  be  justly  attributed  to  heredity. 

The  exposure  to  prolonged  dampness  and  cold,  which  is  necessitated 
by  the  pursuance  of  some  occupations,  is  another  exciting  cause.  This, 
however,  is  most  active  in  those  who  are  predisposed  to  frequent  cold 
catching,  and,  therefore,  scarcely  applies  to  those  who  have  healthy 
throats  and  strong  constitutions.  Persons  who  have  nasal  or  naso- 
pharyngeal  growths  or  chronic  inflammation  of  the  upper  air  space 
bear  exposure  to  cold  and  wet  very  badly,  and  it  is  in  this  particular 
class  of  individuals  that  connective-tissue  deposits  are  most  apt  to  take 
place  in  the  tympanic  cavity.  Certain  general  diseases,  as  tuberculosis, 
syphilis,  and  anemia,  also  predispose  the  individual  to  this  particular 
aural  affection. 

Symptoms. — The  chief  complaints  made  by  the  patient  are  of 
impairment  of  hearing  and  of  head  noises.  Neither  of  these  symptoms 
are,  as  a  rule,  markedly  annoying  in  the  early  stages  of  the  disease,  and 
the  average  patient  usually  ignores  both  until  the  aural  affection  is  well 
advanced,  until  the  function  is  impaired  to  an  extent  that  conversation 
is  heard  with  difficulty,  and  until  such  a  time  as  the  tinnitus  aurium 
becomes  an  ever-present  and  distracting  part  of  the  disease.  Hence, 
whereas  the  patient  may  honestly  state  at  the  time  of  the  first  examina- 
tion that  he  thinks  the  disease  is  of  only  a  few  months',  or  at  most  only 
one  or  two  years'  duration,  yet  careful  inquiry  into  the  history  of  the 
case,  together  with  the  evidence  secured  by  a  physical  inspection  of  the 
ear,  will  prove  beyond  question  that  the  disease  is  of  many  years' 
standing. 

Tinnitus  aurium  is  complained  of  most  bitterly  by  the  patient.  In 
the  earlier  course  of  the  disease  tinnitus  is  usually  present  in  some  degree, 
but  it  is  commonly  intermittent  at  this  period  and  is  seldom  of  distressing 
severity  except  during  the  acute  exacerbation  of  the  ear  disease  which 
arises  from  a  head  cold  or  other  cause.  Gradually,  however,  in  the 
typic  case  the  head  noise  becomes  louder  and  the  periods  of  inter- 
mission shorter,  until  in  the  fully  developed  case  of  chronic  catarrhal 
otitis  media  the  tinnitus  is  constant,  usually  loud  or  high  pitched,  and 
is  always  exceedingly  distressing  to  the  patient.  The  character  of  the 
sound  heard  by  the  patient  varies  greatly,  and  seems  to  be  determined, 
to  some  degree  at  least,  by  the  occupation  or  environment  of  the  individ- 
ual. Thus  the  cook  may  describe  the  noise  as  a  singing  which  resembles 
the  steaming  teakettle;  the  engineer  will  compare  it  to  the  high-pressure 
escaping  steam  from  the  locomotive,  while  those  who  live  in  rural  dis- 


CHRONIC   NON-SUPPURATIVE   OTITIS    MEDIA  479 

tricts  will  often  liken  it  to  the  noise  of  insects.  Tinnitus  aurium  is 
sometimes  described  as  "beating,"  in  which  instance  it  is  found  to 
occur  synchronously  with  the  pulsation  of  the  heart,  and  is  no  doubt 
due  in  such  case  to  some  disturbance  of  the  arterial  circulation  within 
or  near  the  ear.  Sometimes  it  is  intermittent  and  "snapping"  in 
character,  and  this  is  due  either  to  the  passage  of  air  through  the  Eus- 
tachian  tube,  which  contains  thick  mucus,  or,  in  rare  instances,  to  the 
contraction  of  the  tubal  muscles  which  open  the  orifice — namely,  the 
tensor  palati  and  the  levator  palati. 

The  tinnitus  is  frequently  less  intense  during  the  early  morning  hours, 
while  during  the  day  it  is  to  some  extent  forgotten  if  the  patient  is 
constantly  busy  and  is  in  the  midst  of  more  or  less  noise,  as,  for  instance, 
when  upon  the  railway  car,  in  the  busy  street,  the  store,  or  factory.  In 
the  evening,  however,  when  all  is  quiet  and  the  nervous  system  is  some- 
what exhausted  as  a  result  of  the  day's  exertion,  the  head-noise  is  at  its 
height,  and  in  the  worst  cases  the  individual  is  driven  by  it  into  a  state 
of  semimadness.  Such  patients  are  sometimes  unable  to  go  to  sleep 
on  account  of  the  noise,  are  sometimes  awakened  by  it  in  the  night, 
and  are  compelled  to  lie  awake  for  hours,  only  to  listen  to  the  incessant 
confusion  of  sounds  within  their  own  ears.  In  this  state  melancholia  is 
common  and  suicidal  tendencies  and  insanity  more  rarely  occur. 
Impairment  of  junction  is  always  present.  The  degree  of  deafness  is 
governed  largely  by  the  amount  of  obstruction  in  the  Eustachian  tube, 
the  extent  of  the  deposit  of  new  tissue  in  the  tympanic  cavity,  and  by 
whether  or  not  the  labyrinth  is  secondarily  involved.  The  deafness, 
like  the  tinnitus  aurium,  is  bilateral,  although  the  degree  of  impairment 
is  usually  greatest  in  one  ear.  The  patient  may  assert  that  he  hears 
perfectly  in  one  ear,  while  the  hearing  in  the  other  is  greatly  impaired; 
but  a  careful  test  of  the  ear  which  the  patient  believes  is  normal  by 
means  of  the  voice,  whisper,  or  other  accurate  method  will  often  cause 
the  examiner  to  wonder  at  the  statement,  so  greatly  impaired  will  the 
function  of  this  ear  be  found.  The  degree  of  impairment  of  the  function 
varies  greatly  in  many  cases  according  to  the  state  of  the  weather,  the 
general  health  of  the  individual,  and  particularly  as  to  the  quality  of  the 
nerve  tone.  The  hearing  will  be  correspondingly  reduced  in  proportion 
to  the  amount  of  exhaustion  from  overwork,  overanxiety,  or  from  nerve 
fag  due  to  any  cause.  Thus,  the  business  man,  the  student,  or  the 
society  woman  may  hear  without  particular  difficulty  on  arising  in  the 
morning,  but  following  a  day  of  strenuous  activity  along  one  of  these 
lines  the  function  may  be  very  greatly  impaired  for  all  conversational 
tones.  To  one  who  hears  badly,  the  effort  put  forth  to  catch  every  word 


480  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

of  the  day's  conversation  that  is  necessary  in  the  transaction  of  busi- 
ness or  the  discharge  of  social  duties  is  of  itself  a  severe  strain  upon 
the  nervous  system,  and  one  that  as  a  factor  in  the  production  of 
deafness  is  not  always  taken  into  account.  These  patients  often 
become  neurasthenic  from  a  too  constant  and  overanxious  effort  to 
understand  those  with  whom  business  or  social  affairs  may  bring  them 
into  contact. 

A  jeeling  oj  fulness  in  the  head  and  sometimes  of  giddiness  may 
accompany  the  deafness  and  tinnitus.  Rarely  faintness  and  vomiting 
occur,  in  which  instance  the  hearing  is  suddenly  and  more  profoundly 
impaired  and  the  patient  is  for  a  time  compelled  to  remain  quiet  in  bed. 
These  symptoms  are  occasionally  so  severe  as  to  simulate  Meniere's 
disease  (see  p.  529).  The  occurrence  of  the  latter  symptoms  in- 
dicates increased  labyrinthine  pressure  from  hyperemia  of  the  laby- 
rinth vessels  or  from  an  actual  exudate  into  the  labyrinth. 

Pain  is  a  symptom  of  which  complaint  is  rarely  made  at  any  time 
during  the  progress  of  this  long-continued  affection,  and  this  fact  is  no 
doubt  chief  among  the  reasons  why  those  afflicted  with  this  form  of 
aural  ailment  so  frequently  delay  seeking  attention  until  irreparable 
damage  has  been  done  to  the  ear.  The  absence  of  pain  is,  therefore,  an 
unfortunate  circumstance  in  so  far  as  the  results  of  treatment  are  con- 
cerned, since  sufficient  suffering  does  not  occur  to  warn  the  patient  of 
impending  danger  and  to  drive  him  to  seek  relief  for  the  aural  condition. 
When  pain  is  at  all  referred  to  by  the  patient  it  is  not  usually  located  in 
the  ear,  but  more  often  along  the  angle  of  the  jaw  and  over  the  course  of 
the  Eustachian  tube;  or  it  may  be  said  to  be  situated  in  the  throat  in  the 
region  of  the  faucial  pillars  or  lingual  tonsil.  The  pain  in  all  these  in- 
stances is  of  a  neuralgic  character  and  mild  type;  it  is  usually  produced 
more  by  the  condition  existing  in  the  throat  than  by  the  pathologic  state 
within  the  ear.  Occasionally,  when  there  is  sudden  occlusion  of  the 
Eustachian  tube,  pain  of  aural  origin  may  occur.  The  objective  symp- 
toms are  usually  well  marked  and  should  be  accurately  determined  in 
so  far  as  possible  at  the  time  of  the  first  examination  of  the  patient,  for 
the  reason  that  the  prognosis  and  treatment  will  depend  in  great  measure 
upon  the  character  and  amount  of  the  deposit  of  new  tissue  that  has 
taken  place  in  the  Eustachian  tube  and  drum  cavity. 

The  appearance  oj  the  drum-membrane  varies  greatly.  It  may  be 
thickened  or  atrophic,  translucent  or  opaque,  retracted  or  normally 
situated.  Chalky  deposits  are  sometimes  observed.  Adhesions  of 
some  portions  of  the  membrana  tympani,  most  frequently  at  the  umbo 
(see  Figs.  286  and  288),  are  of  common  occurrence.  The  drum  mem- 


CHRONIC   NON-SUPPURATIVE   OTITIS    MEDIA 


481 


brane  is  also  sometimes  thickened  in  one  portion,  whereas  it  is  atrophic 
in  another. 

Opacity  and  retraction  of  the  membrana  tympani  constitute  the  most 
frequent  changes  in  this  structure,  and  when  present  in  any  case  which 
gives  a  history  of  long-standing  deafness  and  tinnitus  aurium,  must  be 
given  great  diagnostic  weight.  Opacity  of  the  membrane  may  exist  in 
the  form  of  a  crescent  which  lies  near  the  annulus  tympanicus  or  it  may 
run  parallel  to  the  annulus,  but  midway  between  it  and  the  umbo  (Fig. 
282).  Sometimes  it  consists  of  an  irregular  circular,  whitish  disc  of 
membrane  surrounding  the  umbo.  In  cases  of  very  long  standing  the 
opacity  may  include  all  or  the  greater  portion  of  the  membrana  vibrans; 
in  this  instance  the  appearance  of  the  entire  structure  is  that  of  frosted 
glass  or  milk-glass,  in  which  can  usually  be  seen  the  faint  outline  of  the 
handle  of  the  malleus,  leading  upward  and  forward  to  the  short  process. 


FIG.  282. — CRESCENTIC  OPACITY  IN  POSTERIOR  HALF 
OF  MEMBRANA  VIBRANS. 

Calcareous  deposit  in  anterior  half.  Shrapnell's  mem- 
brane greatly  depressed. 


FIG.  283. — GREAT  RETRACTION  OF  DRUM  MEMBRANE 

AND  MALLEUS  HANDLE. 

Membrane  is  opaque  and  milk-white.  Landmarks 
almost  obliterated.  Case  of  long  standing  hyper- 
plastic  middle-ear  catarrh. 


All  other  landmarks  of  the  drum  membrane  are  obliterated  by  the  hyper- 
plastic  process  (Fig.  283). *  Where  only  partial  opacity  has  taken  place, 
other  portions  of  the  same  drum  membrane  may  have  a  nearly  normal 
appearance;  or  atrophy  of  some  part  may  have  occurred  to  such  an  extent 
that  the  structures  within  the  middle  ear  may  be  clearly  visible.  Thus, 
the  area  lying  behind  the  malleus  handle  and  just  below  the  posterior 
fold  is  often  so  thin  that  the  malleo-incudal  articulation  can  be  plainly 
seen  (Fig.  284). 

Calcareous  deposits  constitute  one  variety  of  opacity  of  the  drum- 
head. These  may  be  found  single  or  multiple,  may  occupy  a  position 
before  or  behind  the  handle  of  the  malleus,  and  often  lie  midway  between 
it  and  the  annulus  tympanicus.  The  lime  salts  are  frequently  deposited 

1  The  peculiar  tendon-white  color  of  the  membrana  tympani  when  due  to  sclerosis 
is  almost  unmistakable  after  it  is  once  recognized.  The  only  other  condition  for  which 
it  might  be  taken  is  one  of  otitis  externa,  in  which  necrosis  of  the  dermoid  layer  of  the 
drum  membrane  has  taken  place,  is  not  yet  exfoliated,  but  continues  to  cover  the  mem- 
brane and  gives  it  a  dirty  white  appearance. 
31 


482  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

so  as  to  form  an  opacity  of  a  somewhat  semilunar  or  horseshoe  shape 
(Fig.  285),  although  it  may  rarely  assume  an  irregularly  circular  outline. 
When  viewed  by  means  of  reflected  light  the  marked  contrast  of  the 
dead-whitish,  chalky  area  with  the  somewhat  glistening  membranous 
appearance  of  opacities  of  the  milky  variety  will  not  likely  be  mistaken 
for  each  other. 

The  extent  of  retraction  that  has  taken  place  in  the  drum  membrane 
varies  somewhat  with  the  length  of  time  the  disease  has  progressed. 
In  the  earlier  stages  but  little  inward  displacement  may  have  occurred, 
but  later  it  may  be  considerable,  and  usually  forms  one  of  the  diagnostic 
features  (see  Figs.  286  and  289).  The  fact  that  the  drum-head  occupies 
an  indrawn  position  is  determined  largely  by  the  change  it  causes  in  the 
position  of  the  handle  of  the  malleus  and  light  reflex.  The  malleus 
handle  is  usually  displaced  upward,  backward,  and  inward,  but  may 


FIG.  284. — PARTIALLY  OPAQUE  DRUM  MEMBRANE        FIG.  285. — CALCAREOUS    DEPOSIT  IN  DRUM   MEM- 
WITH  SMALL  AREA  OF  ATROPHY  OVER  MALLEO-IN-  BRANE. 

CUDAL  ARTICULATION.  Case  of  long-standing  deafness. 

An  outline  of  this  articulation  is  seen  through  the 
atrophic  area.  The  atrophic  spot  might  easily  be 
mistaken  for  a  perforation. 

rarely  be  drawn  forward  by  contraction  of  the  newly  formed  tissue  in  that 
direction.  When  displaced  backward  the  rotation  of  the  malleus  upon 
its  axis  causes  the  angular  edge  of  the  handle  to  present  toward  the 
examiner,  and  hence  the  appearance  of  the  manubrium  is  narrower  and 
sharper  than  normal,  the  umbo  occupies  a  higher  plane,  and  the  distance 
between  the  umbo  and  the  short  process  appears  very  much  shortened. 
The  short  process  appears  more  prominent  and  whiter  than  normal. 
The  light  reflex  is  lengthened  and,  owing  to  this  fact,  seems  narrower. 
It  is  often  broken  or  multiple  (Fig.  286).  The  posterior  fold  is  exag- 
gerated and  sometimes  a  supernumerary  fold  extends  downward  and 
backward  from  the  short  process  almost  parallel  to  the  handle  of  the 
malleus,  close  to  the  latter,  and  is  finally  lost  in  the  marginal  ring.1 
This  supernumerary  fold  (Fig.  287)  may  be  easily  mistaken  for  the 

1  This  supernumerary  posterior  fold  has  been  described  by  Bing  and  Pomeroy. 


CHRONIC    NON-SUPPURATIVE    OTITIS    MEDIA 


483 


handle  of  the  malleus  unless  careful  examination  regarding  this  point 
be  made. 

When  a  forward  and  inward  displacement  of  the  handle  of  the 
malleus  occurs,  the  latter  assumes  a  more  or  less  perpendicular  position, 
the  short  process  presents  directly  toward  the  examiner,  and  is  therefore 
not  so  prominent  as  in  the  case  of  posterior  indrawing  of  the  membrane. 
Sometimes,  especially  during  the  early  history  of  the  affection,  posterior 
rotation  of  the  malleus  takes  place  independent  of  any  retraction  of  the 
drum  membrane,  in  which  case  the  manubrium  appears  abnormally 
broad  (see  Fig.  282).  But  should  sinking  of  the  drum  membrane  occur 
at  the  same  time  as  the  ossicular  rotation,  the  malleus  handle  would 
seem  narrowed,  as  already  described  (see  Fig.  286). 

The  color  of  the  membrane  may  remain  normal  or  almost  normal 
during  the  earlier  stages  of  the  disease.  Frequently,  however,  some 
congestion  of  Shrapnell's  membrane  or  of  the  membrana  vibrans 


FIG.  286. — GREATLY  RETRACTED  DRUM  MEM- 
BRANE SHOWING  SHARP  BORDER  OF  MALLEUS 
HANDLE,  PROMINENT  SHORT  PROCESS  LONG  LIGHT 
REFLEX,  AND  ADHESIONS  AT  UMBO. 


FIG.  287.— SUPERNUMERARY  POSTERIOR  FOLD. 

Note  the  position  of  the  handle  of  the  malleus, 
which  appears  as  a  narrow  line  just  in  front  of  this 
fold.  Membrana  tensa  greatly  sunken.  Light  reflex 
absent. 


along  the  handle  of  the  malleus  occurs.  During  this  period  the  mem- 
brane may  at  times  have  a  slightly  pinkish  hue.  This  is  owing  to  the 
fact  that  during  the  hyperplastic  progress  of  the  affection  the  mucous 
membrane  of  the  middle  ear  is  greatly  congested,  and  the  color  of  this 
cavity  shows  through  the  semitransparent  membrana  tympani  when 
illuminated  during  the  examination.  The  changes  in  color  due  to 
opacities  from  the  deposit  of  fibrous  tissue  and  calcareous  matter  have 
already  been  described  (p.  481).  During  the  earlier  or  hyperplastic 
stages  of  the  disease  the  tympanum  may  also  contain  yellowish  mucoid 
exudates  which  give  rise  to  a  yellowish  appearance  of  the  drum  mem- 
brane covering  the  area  below  their  level  in  the  drum  cavity;  and  the 
surface  level  of  the  exudate  is  frequently  marked  by  a  thin  black  line 

(Fig-  137)- 

Adhesions  of  the  drum  membrane  may  occur  between  the  promontory 


484  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

and  umbo  (Fig.  288).  An  adhesion  at  this  point  may  be  suspected  when 
the  umbo  seems  very  greatly  depressed,  even  though  no  other  appearance 
may  indicate  such  an  occurrence.  Frequently,  however,  sharply  defined 
bands  of  fibrous  tissue  radiate  from  this  point  and  furnish  unmistakable 
evidence  of  the  fact  that  the  drum  membrane  and  malleus  handle  are 
firmly  united  to  the  inner  tympanic  wall  at  the  promontory  (see  also 


FIG.  288. — ADHESIONS  RADIATING  FROM  THE  UMBO        FIG.   289. — SHOWING  AN  ATROPHIC  AREA  IN  THE 
AND  MANUBRIUM.  MEMBRANE  BELOW  THE  UMBO. 

Immediately  following  the  inflation  of  the  tym- 
panum by  means  of  the  catheter,  this  area  is  seen  to 
bulge  outwardly  into  the  external  canal  like  a  thin 
bladder,  as  shown  in  Fig.  291. 

Fig.  286).  Adhesion  of  Shrapnell's  membrane  to  the  neck  of  the 
malleus  also  takes  place  at  times,  and  this  may  be  recognized  by  the 
sunken  appearance  between  the  bands  of  membrane  leading  to  the 
anterior  and  posterior  spines  of  the  tympanic  ring.  An  adhesion  or 
depression  at  this  point  often  gives  the  appearance  of  a  perforation. 


FIG.  290. — ATROPHIC  AREA  IN  ANTERIOR  HALF  OF  FIG.  291. — BLEB  SEEN  IN  AUDITORY  CANAL  AFTER 

DRUM  MEMBRANE.  CATHETER  INFLATION  OF  TYMPANIC  CAVITY  IN  CASE 

Showing  a  small  point  of  rupture  as  the  result  of  tym-  SHOWN  IN  FIG.  287. 

panic  catheter  inflation.  The  atrophic  area  bulges  like  an  inflated  toy  balloon. 

Atrophic  areas  in  the  drum  membrane  are  not  uncommon.  These 
are  somewhat  round  or  oval,  are  often  surrounded  by  thickened  rims  of 
fibrous  tissue,  and  have  very  much  the  appearance  of  old  perforations 
that  have  been  filled  in  by  the  formation  of  a  delicate  new  membrane. 
These  areas  are  most  frequently  found  posterior  to  the  manubrium 
and  below  the  posterior  fold  (see  Fig.  284),  or  at  the  umbo  (as  shown 


CHRONIC   NON-SUPPURATIVE   OTITIS   MEDIA  485 

in  Figs.  289  to  291).  In  examining  the  drum  membrane  for  points  of 
adhesion,  for  atrophic  areas,  or  for  the  determination  of  the  condition 
of  the  ossicles  as  to  their  mobility,  the  use  of  Siegle's  otoscope  (see 
Fig.  97)  is  of  great  assistance.  When  used  for  this  purpose  the 
attached  bulb  should  first  be  partially  emptied  of  air,  the  speculum 
portion  is  then  inserted  into  the  external  auditory  meatus  so  that 
it  fits  air-tight,  the  auricle  is  retracted  in  the  usual  way,  and  finally, 
while  the  fundus  of  the  ear  is  illuminated,  the  hand  holding  the  air- 
bag  is  relaxed  sufficiently  to  produce  suction  upon  the  membrana 
tympani.  If  there  is  no  adhesion  at  any  point  over  the  membrana 
vibrans,  and  if  the  ossicles  are  not  ankylosed,  the  tympanic  mem- 
brane, together  with  the  handle  ofx  the  malleus,  will  be  seen  to  make 
free  and  unimpeded  outward  and  inward  excursions  as  the  air  in  the 
external  auditory  meatus  is  alternately  rarefied  or  condensed  by  the 
manipulation  of  the  air-bulb.  Should  some  point  of  adhesion  exist, 
the  same  may  be  detected  because  of  its  stationary  position  during 
the  movement  of  all  the  adjacent  parts.  In  case  there  is  ankylosis 
of  the  whole  ossicular  chain  or  of  the  malleo-incudal  articulation,  the 
membrane  on  either  side  of  and  below  the  handle  of  the  malleus  will 
bulge  outward  under  the  influence  of  the  suction  exerted  by  the  otoscope, 
whereas  the  handle  itself  will  remain  stationary. 

Atrophic  areas  in  the  tympanic  membrane  may  be  detected  by  the 
same  process.  Thus,  whereas  other  portions  of  this  structure  are 
displaced  only  under  a  rather  powerful  suction,  or  perhaps  are  not  at 
all  movable,  these  thin  portions  will  be  disturbed  by  the  very  slightest 
suction  from  the  ball  of  the  otoscope,  and  if  strong  suction  be  made 
upon  them,  momentary  bleb-like  projections  will  be  formed  \vhich 
will  mark  their  size  and  location  with  the  greatest  degree  of  accuracy. 

The  Eustachian  tube  is  more  or  less  stenosed  in  the  beginning  of  this 
affection,  and  in  many  cases  this  condition  persists  throughout  all  or  a 
greater  portion  of  the  course  of  the  disease.  The  physical  examination 
must,  therefore,  include  an  accurate  investigation  of  this  portion  of 
the  hearing  organ.  In  this  as  in  every  other  aural  affection  the  condi- 
tion of  the  nose  and  nasopharynx  should  also  be  noted.  During  the 
earlier  stages  of  chronic  non-suppurative  catarrh  of  the  middle  ear 
it  will  usually  be  found  that  adenoids,  chronic  nasopharyngitis,  or  nasal 
disease  exists,  and  even  in  the  more  chronic  cases  of  aural  disease  an 
inflamed  pad  of  adenoid  tissue — the  remnants  of  an  adenoid  growth  in 
earlier  life — may  be  found.  The  nasopharyngeal  mouth  of  each  Eus- 
tachian tube  will  often  be  seen  in  the  earlier  cases  to  be  thickened,  chron- 
ically inflamed,  and  filled  with  a  plug  of  ropy  secretion.  As  the  disease 


486  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

reaches  the  hyperplastic  stage  this  hypersecretion  disappears,  the 
inflammatory  redness  of  the  tubal  orifice  subsides,  and  the  Eustachian 
mouth  frequently  appears  unduly  large  and  pale. 

The  patency  of  the  tube  can  only  be  accurately  determined  by  the 
use  of  the  Politzer  air  douche  or,  preferably,  by  means  of  inflation  with 
the  Eustachian  catheter.  Should  the  Eustachian  tube  be  greatly 
narrowed,  the  sound  heard  by  the  examiner  through  the  auscultation 
tube  during  the  performance  of  an  inflation  (see  p.  190)  will  be  abnor- 
mally high  pitched  because  of  the  passage  of  the  injected  air  through 
an  opening  which  is  narrower  than  normal.  If  total  occlusion  of  the 
tube  has  taken  place  the  inflation  sound  will  be  distant  and  pharyngcal. 
In  many  cases  of  long-standing  non-suppurative  otitis  media  the  tube 
is  abnormally  patent  and  the  air  entering  through  the  catheter  in  great 
volume  is  much  lower  in  pitch. 

An  accurate  functional  examination  is  essential  to  correct  diagnosis, 
and,  therefore,  all  the  physical  tests  should  be  carefully  made.  The 
hearing  distance  for  the  voice,  watch,  and  whisper  will  be  found  reduced 
in  all  cases;  very  much  reduced  in  many,  and  the  various  tests  are  heard 
with  difficulty  or  not  at  all  in  the  most  advanced  forms  of  this  disease. 
Most  patients  will  hear  the  whisper  test  relatively  better  than  the  voice. 
Many  who  hear  quite  well  if  close  to  a  speaker  whose  words  are  clearly 
enunciated,  will  hear  a  less  carefully  trained  voice  very  poorly.  Patients 
will  also  sometimes  hear  words  distinctly  when  they  are  making  no 
particular  effort  to  hear,  when,  if  conscious  that  tests  of  the  hearing  are 
being  made,  will  entirely  fail  to  distinguish  the  same  words  if  spoken 
with  equal  clearness  and  intensity. 

In  uncomplicated  cases  the  hearing  for  the  lower  tuning-forks  is  bad 
and  the  lower  tone  limit  is,  therefore,  said  to  be  raised.  Beginning  in 
the  series  of  the  Hartmann  tuning-forks  with  C,  the  examiner  may  reach 
C1  or  even  C2  before  the  patient  is  able  to  detect  the  sound  (see  Fig. 
115).  The  hearing  for  high  notes  is  but  little  or  not  at  all  impaired  unless 
labyrinthine  complication  exists,  in  which  case  the  high  tone  limit  may 
be  greatly  lowered.  In  uncomplicated  cases  bone  conduction  is  better 
than  air  conduction,  and  the  vibrating  C  fork  when  placed  on  the  center 
of  the  forehead  will  be  heard  better  in  the  worst  ear.  In  making  this 
latter  test  many  patients  will  declare  that  they  heard  the  sound  better 
in  the  good  ear,  without  really  thinking  in  which  ear  the  sound  is  really 
louder.  They  do  this  largely  as  a  matter  of  habit  and  because  they 
think  they  realty  ought  to  hear  all  sounds  better  in  the  good  ear.  Accu- 
rate information  can  only  be  obtained,  therefore,  after  repeated  trials, 
and  after  requesting  the  patient  to  observe  carefully  to  which  ear  the 


CHRONIC   NON-SUPPURATIVE   OTITIS   MEDIA  487 

sound  seems  to  go  and  be  heard  the  louder,  before  making  an  answer. 
In  this  way  the  patient  will  usually  detect  the  error  of  his  former  state- 
ment at  once  and  will  make  the  proper  correction.  The  examiner 
should,  of  course,  give  no  indication  as  to  which  ear  he  thinks  the  patient 
will  hear  the  better  in. 

Prognosis. — The  prognosis  as  to  restoration  of  function  and 
complete  relief  from  the  tinnitus  aurium  is  unfavorable  in  the  great 
majority  of  cases.  During  the  earliest  period  of  the  chronicity  of  this 
aural  affection  and  particularly  when  it  has  been  originally  caused  by 
and  is  yet  kept  alive  because  of  a  coexisting  nasal  or  nasopharyngeal 
disease,  much  benefit  and  sometimes  complete  cure  may  be  promised  as 
the  result  of  treatment.  At  a  later  period, when  tissue  changes  have  taken 
place  in  the  Eustachian  tube,  and  possibly  in  every  part  of  the  tympanic 
cavity;  when  these  have  displaced  the  various  structures  comprising  the 
conducting  portion  of  the  organ  of  hearing,  and  have  bound  them  into 
an  immovable  mass,  no  means  of  treatment  has  as  yet  been  devised 
whereby  the  new  deposits  can  be  absorbed  and  the  contents  of  the  middle 
ear  be  thereby  restored  to  a  normal  condition.  Left  to  nature's  course 
the  disease  is  generally  a  progressive  one,  each  decade  of  the  patient's 
life  ending  with  a  more  greatly  impaired  function  than  the  preceding  one, 
until,  finally,  the  individual  is  able  to  hear  only  the  loudest  conversational 
tones  when  the  speaker  is  near  by.  It  is  a  noteworthy  fact  that  the 
disease  when  uncomplicated  seldom  ends  in  total  deafness,  this  latter 
condition,  as  well  as  the  severer  forms  of  defective  function,  being 
usually  caused  by  some  intercurrent  but  severe  illness  in  which  a  laby- 
rinthine complication  is  developed.  Profound  deafness  may  also  result 
from  tertiary  syphilis  should  this  disease  complicate  some  stage  of  the 
adhesive  aural  catarrh. 

The  environment  and  social  position  of  the  individual  governs  to 
some  extent  the  prognosis;  for  while  the  tendency  of  all  cases  is  to  grow 
gradually  worse,  there  are,  nevertheless,  conditions  of  life  which  cause  the 
progress  of  the  disease  to  be  more  rapid  than  that  normally  observed. 
Among  these  may  be  enumerated  exposure  to  cold  and  damp,  overwork, 
either  of  a  mental  or  physical  variety,  undue  social  activity,  and  constant 
worry  or  anxiety.  Excessive  indulgence  in  tobacco  and  liquors  have 
also  been  enumerated  as  factors  favoring  the  rapid  progress  of  the 
disease.  Intervals  of  arrested  progress  of  the  disease  occur  in  some 
individuals;  these  sometimes  last  for  several  months,  but  finally  the  dis- 
ease is  resumed  with  increased  severity.  Occasionally,  however, 
spontaneous  resolution  takes  place  to  some  degree  and  the  patient 
finally  recovers  a  serviceable  portion  of  the  lost  function. 


488  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

The  prospect  of  material  benefit  in  any  case  is  often  a  doubtful 
one.  Often  those  which  seem  most  promising  either  do  not  improve  at 
all  from  treatment  or  else  get  worse;  on  the  other  hand,  material  benefit 
occasionally  results  from  the  careful  treatment  of  even  the  most  unprom- 
ising aural  condition. 

Although  this  class  of  patients  is  noteworthy  from  the  fact  that  for 
many  years  perhaps  little  thought  is  bestowed  by  the  individual  upon 
the  gradual  loss  of  function,  nevertheless,  when  that  stage  is  reached 
in  which  conversation  is  no  longer  heard  with  ease  and  the  individual 
begins  to  feel  that  he  must  soon  be  ostracised  from  society,  he  suddenly 
becomes  highly  anxious  to  secure  relief  and  never  fails  to  solicit  a  posi- 
tive statement  concerning  the  prognosis  of  the  case  as  soon  as  the  first 
examination  is  completed.  If  such  an  examination  has  been  carefully 
and  intelligently  made  the  examiner  should  be  able  to  give  a  statement 
concerning  the  probable  future  of  the  case  that  will  be  almost  certainly 
verified  by  time.  If  the  disease  is  not  far  advanced,  if  it  is  yet  dependent 
in  a  large  measure  on  the  presence  of  nasopharyngeal  or  nasal  disease, 
and  if  no  labyrinthine  complication  exists,  the  patient  should  be  given 
a  prognosis  of  at  least  the  possibility  of  arresting  the  progress  of  the 
disease  if  not  of  great  improvement  or  cure.  Should,  however,  the 
drum  membrane  be  adherent  to  the  promontory,  the  same  be  thickened 
and  opaque,  the  ossicles  more  or  less  ankylosed,  and  the  Eustachian  tube 
widely  open,  the  prognosis  is  bad,  and  slight  or  no  improvement  should 
be  promised.  Such  an  unfavorable  prognosis  is  particularly  justifiable 
if,  in  addition  to  the  above  physical  conditions,  the  functional  tests 
should  indicate  a  labyrinthine  complication. 

The  prognosis  as  to  satisfactory  relief  or  cure  of  the  tinnitus  aurium 
is  also  unfavorable,  and  particularly  so  after  that  period  of  the  disease 
has  been  reached  in  which  new  deposit  of  connective  tissue  has  taken 
place  in  the  tympanic  cavity.  In  the  earliest  stages,  when  the  tinnitus 
is  partly  due  to  closure  of  the  Eustachian  tube  by  the  swollen  mucous 
membrane  which  lines  this  channel,  or  to  a  congestion  of  the  tympanic 
mucous  membrane  with  a  resulting  collection  of  exudates  in  the  cavity 
of  the  middle  ear,  great  relief  and  frequently  cure  of  the  head  noises 
may  be  promised.  When,  however,  this  symptom  is  due  to  ankylosis  of 
the  foot-plate  of  the  stapes  in  the  oval  window  and,  therefore,  occurs  as 
the  result  of  increased  labyrinthine  pressure  from  this  or  other  causes, 
the  prognosis  should  be  carefully  guarded,  because  the  condition  is  then 
not  often  amenable  to  successful  treatment;  and  in  cases  where  relief  is 
fortunately  experienced  the  improvement  is  usually  of  short  duration 
and  the  tinnitus  quickly  returns  with  its  former  and  sometimes  with  an 


CHRONIC   NON-SUPPURATIVE   OTITIS    MEDIA  489 

increased  severity.  It  is  a  matter  of  common  observation,  however, 
that  in  many  cases  where  the  disease  has  been  worse  in  one  ear,  that 
after  a  period  of  years  the  perception  for  the  tinnitus  seems  to  be 
exhausted,  and  the  patient  experiences  spontaneous  relief  in  that  ear. 
Unfortunately,  however,  the  tinnitus  often  becomes  simultaneously  worse 
in  the  better  ear,  in  which  latter  it  runs  a  more  violently  exasperating 
course  than  in  the  ear  first  affected. 


CHAPTER  XL 
CHRONIC  NON-SUPPURATIVE  OTITIS  MEDIA  (Continued) 

TREATMENT 

THE  treatment  consists  in  efforts  to  arrest  the  progress  of  the  disease 
and  to  restore  as  far  as  possible  the  affected  parts  to  the  normal.  More 
practically  speaking,  the  treatment  should  aim  to  restore  the  impaired 
hearing  and  to  abolish  the  intolerable  tinnitus. 

Should  the  patient  be  so  fortunate  as  to  consult  the  aurist  early  in 
the  course  of  the  disease  and,  therefore,  before  sclerotic  processes  have 
been  established,  the  first  duty  should  be  to  restore  the  diseased  nose 
or  nasopharynx  as  nearly  as  possible  to  the  normal.  It  has  already 
been  pointed  out  that  hypertrophies  or  new  growths  and  inflammatory 
states  of  the  upper  air  tract  are  not  only  the  chief  causes  of  the  affection 
in  question,  but  that  their  continued  presence  in  this  location  also 
furnishes  the  main  reason  for  its  continued  progress.  All  such  abnor- 
malities should,  therefore,  be  removed  as  speedily  as  possible,  since 
no  treatment  of  the  ear  alone,  however  well  directed,  can  prove  per- 
manently beneficial  so  long  as  a  diseased  environment  of  this  organ  is 
allowed  to  remain  and  to  exert  a  continuously  harmful  influence  upon 
that  organ  (see  Chapter  XIX.). 

The  character  of  the  treatment  of  this  disease  at  any  stage  of  its 
progress  should  depend  entirely  upon  the  pathologic  conditions  found 
to  be  present  at  the  first  and  subsequent  examinations.  No  set  rules 
of  practise  can,  therefore,  be  established  which  would  be  applicable 
to  every  case,  for  it  must  be  remembered  that  one  patient  may  be  seen 
by  the  aurist  before  the  disease  is  of  many  months'  standing,  whereas 
it  may  be  found  that  the  next  patient  may  have  been  afflicted  for  a  period 
of  twenty-five  years  or  more.  The  conditions  present  in  each  may, 
therefore,  be  vastly  different  and  the  methods  of  treatment  must  be 
correspondingly  so. 

When  the  Eustachian  tube  is  partly  or  wholly  occluded,  the  same 
should,  if  possible,  be  restored  to  its  normal  degree  of  patency.  The 
Eustachian  catheter  furnishes  the  best  means  of  inflating  the  tympanic 
cavity,  and  whereas  the  patient  will  receive  the  benefit  of  the  air  which 
is  injected  by  this  method,  the  operator  will  also  be  able  to  judge,  by 

490 


CHRONIC    NON-SUPPURATIVE   OTITIS    MEDIA  491 

means  of  the  auscultation  tube,  the  degree  of  obstruction  present.  In 
case  the  occlusion  is  due  solely  to  a  congestion  of  the  mucous  membrane 
of  the  tube,  as  is  frequently  true  in  the  early  stage,  and  especially  when 
this  congestion  is  due  to  the  presence  of  nasopharyngeal  disease,  the 
repeated  inflation  of  the  tympanic  cavity  will  often  prove  sufficient  to 
relieve  the  congestion  and  thereby  correct  the  stenosis  of  the  tube. 
The  free  admission  of  air  into  the  tympanum  as  a  result  of  the  catheter 
inflation  likewise  replaces  the  sunken  membrana  tympani,  empties 
the  engorged  venous  channels  of  both  the  tube  and  tympanic  cavity, 
and  thus  this  simple  measure  ultimately  restores  the  lost  function  and 
abates  the  tinnitus.  The  catheter  inflation  should  not,  as  a  rule,  be 
practised  oftener  than  every  second  or  third  day,  for  the  reason  that 
when  too  frequently  performed  the  aural  condition  sometimes  becomes 
worse  instead  of  better. 

When  the  inflation  of  air  alone  fails  to  make  satisfactory  improve- 
ment, medicated  vapors  (see  foot-note)  should  be  substituted,  and  the 
treatment  by  this  means  carried  out  for  a  period  of  from  four  to  six 
weeks.  Stimulating  vapors  may  be  conveniently  substituted  for  air 
during  catheter  inflation  by  the  interposition  of  a  reservoir  containing 
the  substance  to  be  vaporized  between  the  cut-off  and  the  catheter. 
By  this  means  the  air  current  passes  over  the  volatile  substance  which 
it  is  desired  to  blow  into  the  tympanum  before  it  enters  the  catheter. 
Several  vaporizing  devices  are  in  use.  Those  of  Hartmann  and  Pynchon 
are  simple,  convenient,  and  efficient.  Each  consists  of  a  small  elliptic 
shell  of  glass,  metal,  or  hard  rubber,  with  a  fitting  at  one  end  for  insertion 
into  the  mouth  of  the  Eustachian  catheter,  while  in  the  other  end  is 
a  receptacle  for  the  nozzle  of  the  air-bag  or  cut-off.  A  small  amount 
of  cotton  is  placed  in  the  interior  of  the  vaporizer  and  on  this  is  dropped 
a  few  drops  of  the  stimulating  solution  which  is  inserted  for  the  vapor- 
ization just  before  the  performance  of  the  inflation.1 

Bench's  vaporizer  (Fig.  292)  provides  an  excellent  means  of  inflating 
the  tympanic  cavity  with  medicated  vapors.  The  instrument  is  so 
constructed  that  by  merely  turning  a  key  in  the  top  of  the  bottle  either 
air  alone  or  medicated  air  may  be  used.  This  provision  is  of  advantage 

1  The  substances  most  frequently  employed  as  stimulating  vapors  for  tympanic  inflation 
are  iodin,  menthol,  camphor,  eucalyptol,  oil  of  pine,  and  chloroform  and  ether.  lodin  is 
most  conveniently  used  in  the  form  of  the  official  tincture.  Combinations  of  the  above 
drugs  are  sometimes  more  efficacious  or  soothing  than  one  single  remedy.  The  liquid 
which  results  from  the  trituration  of  equal  parts  of  camphor  gum  and  menthol  crystals 
forms  the  most  convenient  method  of  using  these  two  combined.  A  few  drops  of  this 
camphor -menthol  solution  are  dropped  on  the  cotton  contained  in  the  vaporizing  instru- 
ment, and  the  subsequent  inflation  of  the  tympanic  cavity  is  both  soothing  and  stimulating 
to  the  auditory  tract. 


492 


THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 


in  those  cases  where  there  is  an  oversecretion  of  mucus,  which  fills  the 
Eustachian  tubal  orifice  and  perhaps  extends  for  some  distance  inward 
toward  the  tympanum.  In  such  instances  it  is  desirable  to  use  air 
alone  until  the  tube  is  blown  free  from  mucus,  after  which  the  key  in  the 
bottle  is  turned  and  the  tympanic  cavity  is  inflated  with  the  medicated 
vapor.  Should  neither  of  these  methods  result  satisfactorily  or  should 


FIG.  292. — DENCH'S  VAPORIZER  WITH  CATHETER  ATTACHED  READY  FOR  INSERTION. 

it  be  found  that  the  Eustachian  tube  is  so  narrow  that  but  little  or  on 
air  can  be  injected  through  the  catheter  into  the  tympanic  cavity,  the 
inflation  must  first  be  preceded  by  the  passage  of  the  Eustachian  bougie 
(Fig.  293). 

The  technic  oj  introducing  the  Etistadiian  bougie  should  be  executed 
with  the  greatest  precision  and  gentleness,  since  otherwise  abrasion  of 


i'lG.  293. — EUSTACHIAN  BOUGIE. 

the  mucous  membrane  of  the  Eustachian  tube  may  be  produced,  and 
subsequently,  during  the  inflation  through  the  tube,  a  quantity  of  air  may 
be  forced  through  the  rent,  under  the  mucous  membrane,  and  a  trouble- 
some or  even  dangerous  emphysema  may  thus  result.  All  nasal  and 
nasopharyngeal  mucus  should  be  first  removed  by  spraying  the  nose 
and  nasopharynx  before  the  attempt  is  made  to  pass  the  bougie.  Par- 


CHRONIC    NON-SUPPURATIVE   OTITIS   MEDIA  493 

ticular  attention  should  be  given  to  this  latter  cavity,  especially  in  the 
region  of  the  mouth  of  the  Eustachian  tube.1  A  Eustachian  catheter  is 
selected  with  a  short  shank  and  a  beak  of  long  curve  (Fig.  106).  The 
caliber  of  this  instrument  should  be  large,  in  order  to  permit  the  passage 
of  the  bougie  without  the  necessity  of  any  undue  forcing.  The  bougie 
is  then  dipped  in  vaselin  and  passed  through  the  catheter  until  its  tip 
appears  at  the  mouth  of  the  beak,  but  does  not  project  from  it.  The 
catheter  thus  prepared  is  next  inserted  through  the  nostril  in  the  usual 
way  (see  p.  185),  and  when  the  beak  is  known  to  have  entered  the 
pharyngeal  mouth  of  the  tube  and  to  fit  snugly  and  deeply  into  the 
tubal  orifice,  the  bougie  is  gently  pushed  inward  through  the  catheter 
for  a  distance  not  to  exceed  ij  in.  (Fig.  294);  the  distal  end  of  the 
bougie  meanwhile  traversing  the  length  of  the  Eustachian  tube.  During 


FIG.  294. — BOUGIE  AND  CATHETER  AS  SEEN  IMMEDIATELY  AFTER  INSERTION. 
The  bougie  projects  from  the  catheter  ij  in. 

the  successful  passage  of  the  bougie  the  patient  complains  of  a  slight 
stinging  pain  in  the  ear,  neck,  or  occiput,  and  sometimes  in  the  teeth, 
whereas  if  the  bougie  has  doubled  upon  itself,  as  it  may  sometimes 
do,  and  its  point  has  returned  into  the  nasopharynx  instead  of  pur- 
suing the  desired  course,  the  patient  will  complain  of  the  pain  in 
this  latter  region  instead  of  in  the  former,  as  above  stated.  The  chief 
means  of  knowing  that  the  bougie  has  taken  the  desired  course  through 
the  Eustachian  tube  are  furnished  by  the  location  of  the  pain  during 
its  passage  and  by  the  distance  of  its  insertion  following  the  proper 
introduction  of  the  catheter.  In  case  the  posterosuperior  quadrant 
of  the  membrana  tympani  is  atrophic  and  semitransparent,  an  exam- 
ination of  the  fundus  of  the  ear  while  the  bougie  is  in  place  may 

1  In  the  very  chronic  stages  of  the  disease  no  secretion  will  likely  be  present  in  the 
neighborhood  of  the  tubal  orifices,  and  the  cleansing  part  of  the  procedure  is,  therefore, 
unnecessary. 


494  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

reveal  the  tip  of  the  little  instrument  in  the  cavum  tympani.  When 
seen  under  such  circumstances  the  head  of  the  bougie  occupies  a  posi- 
tion slightly  below  and  posterior  to  the  short  process  of  the  malleus. 
Should  it  be  pushed  more  deeply  through  the  catheter,  and  consequently 
further  into  the  Eustachian  tube,  it  would  perforate  the  membrana 
tympani  in  this  position.  When  once  the  bougie  has  been  properly 
passed  through  the  Eustachian  tube  it  will  hold  the  catheter  in  place 
without  further  assistance  from  the  operator,  and  in  this  position  it 
should  be  allowed  to  remain  for  from  five  to  ten  minutes  in  order  to 
secure  the  full  benefit  of  the  dilating  force.  In  cases  where  the  tubal 
stenosis  is  due  largely  to  congestion  or  inflammatory  swelling  and  not 
to  connective  tissue  or  fibrous  deposits,  better  results  will  be  secured 
from  the  passage  of  the  bougie  if  it  is  first  dipped  into  a  solution  of  silver 
nitrate  of  a  strength  of  30  or  40  gr.  to  the  ounce,  and  is  then  passed  into 
the  swollen  tube  and  allowed  to  remain  for  a  few  minutes,  as  stated. 
In  addition  to  the  application  of  a  silver  nitrate  solution  to  the  whole 
length  of  the  Eustachian  tube,  additional  good  results  will  be  obtained 
if  the  same  solution  be  painted  over  the  vault  of  the  nasopharynx, 
around  the  lips  of  the  pharyngeal  mouth  of  the  tube,  and  as  deeply 
into  the  tubal  mouth  as  possible  by  the  use  of  a  cotton-tipped,  curved 
applicator.  In  making  this  application  the  soft  palate  must  be  retracted 
by  White's  retractor  (Fig.  118),  and  the  application  is  made  to  the 
desired  areas  by  means  of  reflected  light  and  the  postrhinoscopic  mirror, 
lodin  and  astringent  applications  may  be  substituted  for  the  silver  if 
such  be  thought  to  be  indicated.  When  the  stenosis  of  the  Eustachian 
tube  is  of  very  long  standing  and  is  due  to  the  deposit  of  fibrous  tissue, 
the  electric  bougie,  as  advocated  by  Duel  and  others,  is  of  greater  benefit 
than  the  passage  of  the  simple  catgut  or  whalebone  instrument. 

Whatever  may  have  been  the  cause  of  the  narrowing  or  closure  of 
the  tube,  and  whatever  may  have  been  the  means  of  relief,  recurrence  of 
the  trouble  is  the  rule,  and  it  must  be  expected  that  the  dilation  will  need 
repeating  after  an  interval  of  some  weeks  or  months.  Moreover,  the 
same  degree  of  relief  is  not  always  obtainable  during  subsequent  treat- 
ment that  was  secured  at  the  first. 

In  those  cases  of  exudative  middle-ear  catarrh  of  the  acute  variety  in 
which  resolution  has  not  taken  place  and  in  which  the  disease  has  entered 
the  chronic  state,  this  exudate  must,  if  possible,  be  removed  from  the 
tympanic  cavity  and  the  attempt  be  made  to  prevent  its  further  formation. 
The  methods  of  dealing  with  such  exudates  within  the  tympanic  cavity 
have  already  been  described  in  a  previous  chapter  (see  p.  247);  and  the 
plan  of  dealing  with  these  products  in  the  chronic  form  differs  in  no  way 


CHRONIC    NON-SUPPURATIVE   OTITIS   MEDIA  495 

from  that  stated  therein,  with  the  exception,  of  course,  that  the  more 
chronic  the  form  of  the  disease  the  more  stimulating  must  be  the  treat- 
ment and  the  more  persistent  the  efforts  to  secure  the  desired  result. 
The  employment  of  medicated  vapors  in  the  middle  ear  by  means  of 
catheter  inflation  should  be,  therefore,  persistently  carried  out  after  the 
evacuation  of  the  exudate  has  been  accomplished  by  incision.  These 
vapors  prove  beneficial  through  their  stimulating  action  upon  the  vas- 
cular supply  to  the  middle  ear.  Under  their  employment  an  additional 
inflammatory  action  is  set  up  in  the  mucous  lining  of  the  cavity,  during 
the  subsidence  of  which  absorption  of  the  newly  deposited  tissue  elements 
takes  place.  Since  these  vapors  are  introduced  by  means  of  catheter 
inflation  of  the  tympanic  cavity,  much  of  the  benefit  arising  from  this 
plan  of  treatment  should  probably  be  attributed  to  the  inflation  alone. 

Dry  Middle-ear  Catarrh. — After  the  continuance  of  the  exudative 
form  of  the  disease  for  a  varying  length  of  time,  from  one  to  several 
years,  all  catarrhal  exudate  ceases  as  a  result  of  glandular  destruction 
and  a  dense  fibrous  tissue  is  formed  throughout  the  middle  ear  and  tube. 
Owing  to  the  tendency  toward  the  formation  of  adhesions  between  adja- 
cent surfaces,  the  disease  is  at  this  period  often  called  adhesive  catarrh 
of  the  middle  ear;  and  again,  because  of  the  absence  of  secretion,  it  is 
designated  otitis  media  catarrhalis  sicca,  or,  as  more  commonly  stated, 
dry  middle-ear  catarrh.  At  this  stage  all  hope  of  accomplishing  a  cure 
must  be  abandoned  and  the  most  that  can  be  expected  in  any  case  is  to 
improve  the  hearing  and  mitigate  the  tinnitus ;  and  even  this  hope  is  not 
always  realized,  for  many  cases  must  be  dismissed  following  the  first 
examination  with  the  statement  that  all  treatment  would  be  useless. 

The  chief  methods  of  dealing  with  this  advanced  condition  are: 
Inflation  by  stimulating  vapors,  massage  of  the  membrana  tympani  and 
of  the  ossicular  chain;  general  medication,  including  hygienic  measures; 
and,  lastly,  surgical  procedures  directed  toward  the  relief  of  tension  or 
obstruction  due  to  the  advanced  adhesive  processes. 

By  the  inflation  of  medicated  vapors  into  the  ear  it  is  believed  that 
the  adhesive  process  is  often  retarded  in  its  progress  or  is  perhaps  some- 
times arrested  and  the  adventitious  products  of  the  disease  to  a  slight 
extent  absorbed.  In  some  instances  the  hearing  is  improved  by  the 
inflation  of  these  vapors,  and  the  distressing  tinnitus  is  thereby  lessened 
or  greatly  relieved.  On  the  contrary,  however,  the  opposite  effects  are 
sometimes  obtained.  When  improvement  is  to  follow  this  plan  of 
treatment  some  increase  in  the  hearing  will  be  noticed  by  the  patient 
immediately  after  the  first  inflation  is  performed,  and  some  additional 
gain  will  probably  be  observed  after  each  of  the  next  several  treatments, 


496  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

following  which  the  gain  will  become  somewhat  stationary  and  will 
likely  remain  so  during  the  course  of  subsequent  inflations.  Inflation, 
either  of  air  or  medicated  vapors,  should  not  be  given  too  frequently  or 
continued  for  too  long  a  period.  The  best  results  will  usually  be  ob- 
tained from  this  method  when  performed  every  second  or  third  day. 
When  carried  out  at  these  intervals  for  any  greatly  prolonged  period 
the  patient  after  a  time  is  apt  to  grow  worse.  The  term  of  treatment 
should,  therefore,  not  usually  be  longer  than  six  weeks,  and  often  four 
weeks  should  be  the  limit.  Certainly  if  the  patient  complains  of  an 
increase  of  the  tinnitus  or  of  a  lessening  of  the  hearing  at  any  time, 
when  improvement  had  followed  the  first  few  treatments,  the  shorter 
period  above  mentioned  should  be  considered  the  limit.  Upon  dis- 
missal from  such  a  course  the  patient  should  be  instructed  to  continue 
without  further  treatment  until  the  hearing  is  found  to  be  again  dimin- 
ishing, at  which  time  the  inflations  may  be  profitably  repeated.  In  any 
case  in  which  no  betterment  is  secured  from  the  first  few  treatments,  the 
plan  should  be  abandoned.  If  made  worse  by  the  first  inflation  this 
procedure  should  not  be  repeated. 


FIG.  295. — LDCAE'S  PRESSURE  PROBE. 
The  base  of  the  probe  rests  upon  a  spring  situated  in  the  handle  of  the  instrument. 

Massage  of  the  drum  membrane  and  ossicular  chain  is  best  performed 
in  connection  with  the  simultaneous  inflation  of  vapors  into  the  tympanic 
cavity.  Its  purpose  is  to  prevent  the  formation  of  adhesions  between  the 
membrane  and  inner  wall  of  the  middle  ear  and  also  to  prevent  or  to 
break  up  the  ankylosed  state  of  the  ossicular  chain.  The  accomplish- 
ment of  these  ends  is  desirable  in  all  cases  and  if  accomplished  even  in 
a  small  measure,  both  the  hearing  and  the  tinnitus  will  most  usually  be 
benefited.  The  chief  instruments  employed  for  this  purpose  are  some 
form  of  Siegle's  otoscope  (see  Fig.  97),  Lucae's  pressure  probe  (Fig. 
295),  and  Delstanche's  masseur.  The  first  and  last-named  appliances 
act  upon  the  drum  membrane  by  means  of  a  rarefaction  of  the  air  which 
their  use  produces  in  the  external  auditory  meatus  and,  as  a  result  of 
which,  the  membrane  is  caused  to  make  outward  and  inward  excursions. 
Because  of  the  attachment  of  the  ossicular  chain  to  the  drum  membrane 
the  oscillations  produced  upon  this  structure  by  rarefaction  and  con- 
densation of  the  air  in  the  external  auditory  meatus,  also  moves  the 
ossicles  at  the  same  time.  Not  every  ear  in  which  the  adhesive  process 
is  present  is  a  proper  one  for  the  application  of  this  form  of  massage 


CHRONIC    NON-SUPPURATIVE    OTITIS   MEDIA  497 

treatment,  for,  as  has  been  already  pointed  out,  the  membrana  tympani 
of  many  of  these  cases  is  atrophic  in  certain  areas,  whereas  the  remaining 
portion  may  be  thickened  and  adherent  to  the  promontory.  The  long 
process  of  the  hammer  being  thus  bound  down  at  its  tip,  whereas  the 
malleo-incudal  joint  is  firmly  fixed  by  the  deposit  of  fibrous  tissue  around 
its  articulation,  these  ossicles  are  absolutely  immovable,  and  hence  any 
suction  exerted  upon  the  membrana  by  means  of  any  instrument  which 
acts  upon  the  principle  of  the  Siegle's  otoscope,  will  only  act  upon  the 
atrophic  and  unattached  portions,  whereas  the  hypertrophied  areas 
and  the  ossicular  chain  are  unaffected  by  the  treatment.  Much  harm 
is,  therefore,  likely  to  result  from  the  rarefaction  of  the  air  in  the  external 
auditory  meatus,  especially  if  the  manipulation  be  frequently  repeated, 
in  all  cases  where  there  is  either  atrophy  of  the  whole  or  a  portion  of  the 
membrana  tympani.  These  massage  instruments  which  act  through  the 
suction  of  the  rubber  hand-ball,  as  in  Siegle's  otoscope,  or  from  the 
exhaust  of  a  small  pump  propelled  by  an  electric  or  water  motor,  are 
capable,  therefore,  of  doing  much  harm  if  indiscriminately  employed  in 
this  class  of  disease,  for  the  reason  that  the  suction  increases  the  degree 
of  relaxation  in  a  membrane  which  is  at  least  in  part  already  too  lax. 
Hence,  when  conditions  of  atrophy  of  the  tympanic  membrane  are 
present,  the  use  of  all  instruments  of  this  class  is  positively  contra- 
indicated.1  Instruments  of  this  type  have  been  produced  in  such  attrac- 
tive patterns  and  alleged  utility  in  the  treatment  of  deafness,  that  they 
now  form  a  portion  of  the  armamentarium  of  many  physicians,  and  the 
temptation  to  use  them  on  all  cases  of  deafness,  without  first  having 
ascertained  the  exact  nature  of  the  disease,  and,  therefore,  without 
knowing  whether  or  not  the  particular  case  is  a  proper  one  for  suction 
massage,  has  been  so  great  that  much  damage  has  already  been  done 
from  this  source.  The  employment  of  all  suction  apparatus  is  positively 
contra-indicated  until,  by  accurate  examination  of  the  membrana  tym- 
pani, the  physician  has  assured  himself  that  a  relaxed  drum  membrane 
does  not  exist. 

Lucae's  pressure  probe  acts  upon  the  ossicular  chain,  and  through 
it  upon  the  membrana  tympani.  During  its  use  the  little  cup  at  the 
end  of  the  probe  is  intended  to  be  accurately  placed  over  the  short 
process  of  the  malleus,  so  that  pressure  upon  the  handle  of  the  in- 
strument, exerted  by  the  operator,  will  move  the  whole  chain  of 
bones.  This  procedure,  even  when  skilfully  executed,  is  usually  quite 
painful  and  few  patients  will  tolerate  it  for  any  length  of  time.  Lucae 

1  Charlatans  use  the  electric  suction  instrument  on  every  case  of  deafness  regardless 
of  the  cause,  stage  of  the  disease,  or  the  condition  of  the  membrana  tympani. 
32 


498  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

in  his  practise  wraps  a  thin  layer  of  cotton  over  the  cup-shaped  end 
and  then  dips  this  into  ice-water  before  applying  the  instrument  to  the 
short  process.  He  claims  that  these  precautions  very  greatly  limit  the 
amount  of  pain  produced  by  the  manipulation. 

When  suction  apparatus  is  employed  for  the  purpose  of  increasing 
the  mobility  of  the  membrana  tympani  and  ossicular  chain,  a  certain 
degree  of  caution  must  always  be  exercised  by  the  surgeon  in  order  to 
avoid  actual  harm  resulting  from  its  ill-advised  use  or  from  its  overuse. 
In  the  first  place,  no  suction  apparatus  should  ever  be  employed  for  this 
purpose  unless  it  is  so  constructed  that  the  operator  is  able  to  actually 
see  the  fundus  of  the  ear  through  the  speculum  portion,  and  is  thus 
able  to  note  the  effect  upon  the  drum-head  of  each  individual  rarefaction 
that  is  produced  in  the  external  auditory  meatus.  Siegle's  speculum 
otoscope  is,  therefore,  the  best  instrument  that  can  be  employed  for 
mobilization  of  these  structures,  because  it  is  so  constructed  that  the 
operator  can  see  the  exact  extent  of  every  movement  induced  in  the 
whole  membrane  or  in  the  several  segments  of  the  drum-head.  By 
noting  precisely  the  effect  of  this  procedure  upon  the  visible  portions 
of  the  conducting  apparatus  the  operator  may  wisely  conclude  that 
the  membrane  is  already  too  much  relaxed  in  whole  or  in  part,  that, 
therefore,  massage  would  be  decidedly  harmful  to  the  particular  case,  and 
that,  therefore,  this  method  of  treatment  should  at  once  be  abandoned. 
It  may  also  be  observed  through  this  pneumatic  speculum  that,  whereas 
the  membrana  vibrans  moves  freely  under  the  influence  of  the  suction, 
the  handle  of  the  malleus  remains  stationary  because  of  adhesions 
between  its  tip  and  the  promontory  of  the  middle  ear,  or  because  of 
ankylosis  of  the  malleo-incudal  articulation.  Persistence  in  the  use  of 
the  suction  apparatus  after  this  condition  is  seen  to  exist  will  usually 
result  in  an  increase  of  damage  to  the  patient's  ear.  It  may  also  be 
seen  while  observing  the  behavior  of  the  drum-head  when  influenced  by 
the  suction,  that  whereas  both  membrana  tympani  and  ossicular  chain 
can  be  made  to  move  outward  and  inward  at  the  will  of  the  operator, 
that  a  too  powerful  suction  will  produce  an  unnecessarily  wide  excursion, 
whereas  a  weaker  suction  will  produce  no  excursion  at  all.  The  operator 
will,  therefore,  be  able  when  using  the  Siegle  pneumatic  speculum  to 
accurately  judge  by  actual  observation  at  the  instant  the  drum-head  is 
moved  the  precise  amount  of  force  necessary  to  produce  the  desired 
amount  of  motion  in  the  membrana  and  ossicular  chain,  and  by  this 
information  will,  therefore,  be  enabled  more  intelligently  to  carry  out 
the  subsequent  treatments.  Hence,  good  result  should  be  expected 
from  the  employment  of  suction  massage,  only  when  its  use  is  governed 


CHRONIC   NON-SUPPURATIVE   OTITIS   MEDIA  499 

by  the  above  information  concerning  the  behavior  of  the  drum-head 
and  ossicles  when  influenced  by  suction,  and  as  actually  witnessed 
through  the  pneumatic  aural  speculum.  It  is  clearly  improper,  therefore, 
to  use  any  form  of  double-suction  apparatus  which  is  intended  to  massage 
both  ears  of  the  patient  simultaneously,  for  the  reason  that  it  is  impossible 
for  the  operator  to  observe  the  effect  of  such  treatment  upon  both  ears 
at  the  same  instant.  This  topic  may  be  dis- 
missed with  the  statement  that  many  patients 
will  not  be  at  all  affected  by  suction  massage; 
only  a  few  are  improved  by  its  most  careful 
employment  and  all  may  be  made  worse  by 
its  indiscriminate  and  unscientific  use.1 

In  addition  to  whatever  good  effect  may 
result  from  the  massage  of  the  drum  mem-          FlG.  2Q6._lNDRAWN  DRUM. 

brane    by    the    foregoing    method,    an    increase       HEAD,  SHOWING  INJECTED  BLOOD- 
VESSELS ALONG  THE  HANDLE  OF 

in    the    blood     Supply     tO     the    affected    parts    is       THE   MALLEUS    AFTER    OTOMAS- 

induced.  Thus,  immediately  following  the  OTGOESC^E.  MEANS  °F  SlEGLE's 
manipulations  with  the  otoscope,  it  will  be 

seen  that  the  blood-vessels  along  the  handle  of  the  malleus  become 
injected  and  may  be  traced  across  the  tympanic  field,  as  shown  in 
Fig.  296. 

The  internal  administration  of  drugs  is  indicated  when  the  patient 
is  anemic,  tuberculous,  syphilitic,  or  when  the  local  treatment  of  the  ear 
has  not  proved  effective  for  the  relief  of  the  tinnitus  aurium.  Anemia 
is  best  combatted  by  some  preparation  of  iron,  taken  in  conjunction 
with  an  outdoor  life.  The  food  and  exercise  of  this  class  of  patients 
should  be  so  regulated  as  to  stimulate  the  nutritive  functions  to  their 
fullest  physiologic  capacity.  The  tuberculous  case  which  is  com- 
plicated by  this  particular  class  of  ear  affection  must  in  a  general  way 
be  treated  by  the  administration  of  drugs  which  will  improve  the  nutri- 

1  Another  method  by  which  pneumatic  massage  may  be  practised  upon  the  drum-head 
and  ossicles  has  been  described  by  Hommel.  This  consists  of  pressing  the  tragus  into 
the  auditory  meatus,  whereby  the  air  in  the  auditory  canal  is  condensed,  and  then  quickly 
relaxing  the  pressure  and  allowing  the  tragus  to  recover  its  normal  position.  The  finger 
of  the  operator  or  of  the  patient  is  the  only  instrument  necessary  for  the  performance  of 
this  method.  The  movement  of  quickly  forcing  the  tragus  into  the  meatus  and  then 
quickly  relaxing  the  same  is  repeated  one  hundred  or  more  times  at  each  daily  treatment. 
If  the  drum  membrane  is  not  greatly  thickened  or  adherent  it  is  stated  that  some  motion 
can  be  imparted  both  to  it  and  to  the  ossicular  chain,  and  benefit  sometimes  results  from 
this  practise  to  the  extent  that  the  hearing  is  improved  and  the  tinnitus  lessened.  Since 
by  it  the  drum-head  is  always  displaced  inward,  instead  of  being  lifted  outward  as  is  the 
case  when  the  pneumatic  speculum  is  used,  Hommel's  method  is  inferior  to  the  other, 
and  is  only  suited  to  home  treatment  by  the  patient  himself. 


5<DO  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

tion,  and  the  individual  should  be  encouraged  to  live  as  much  as  possible 
in  the  open  air  and  sunshine.  If  the  climate  in  which  he  lives  is  not 
such  as  to  permit  an  outdoor  life,  advantage  to  the  diseased  ear,  as  well 
as  to  the  tuberculous  state  will  be  gained  by  the  removal  to  a  warm, 
dry,  and  moderately  elevated  region.  Syphilis  affects  the  ear  more 
frequently  than  is  commonly  recognized.  In  chronic  catarrhal  otitis 
media  it  is  most  often  observed  in  the  tertiary  stage  of  the  specific 
disease  and,  therefore,  the  iodids  of  potassium  or  sodium  are  indicated 
in  increasingly  large  doses  and  until  their  effect  upon  the  disease  is 
clearly  manifested.  If  mercury  is  to  be  used  to  improve  the  luetic 
aural  symptoms  it  is  best  employed  in  the  form  of  an  ointment,  which 
should  be  rubbed  into  the  tissues  of  the  neck  once  a  day  for  a  period 
of  two  weeks,  then  intermitted  a  week  and  again  repeated,  the  whole 
treatment  covering  a  period  of  six  or  eight  weeks.  No  doubt  much  of 
the  good  attributed  to  the  mercury  when  used  in  this  manner  is  due 
to  the  massage  of  the  neck  which  is  necessary  in  rubbing  the  ointment 
through  the  skin,  and,  therefore,  if  the  massage  be  thoughtfully  per- 
formed according  to  some  definite  plan  the  results  are  apt  to  be  more 
satisfactory  than  when  the  ointment  is  merely  rubbed  in. 

For  the  relief  of  the  distressing  tinnitus  aurium  it  is  often  necessary 
to  prescribe  some  form  of  internal  medication.  The  drugs  most  useful 
for  this  purpose  are  the  bromids  of  sodium  and  potassium  and  dilute 
hydrobromic  acid.  In  general,  the  bromids  are  more  beneficial,  because 
it  is  frequently  the  case  that  the  patient  who  suffers  greatly  from  tinnitus 
soon  becomes  highly  nervous,  sleepless,  and  often  melancholic — condi- 
tions for  which  these  latter  drugs  prove  especially  serviceable.  When 
given  for  the  purpose  of  relieving  head  noises  the  bromids  must  usually 
be  prescribed  in  doses  of  from  15  to  20  gr.  one  or  more  times  a  day. 
It  is  found  advantageous  to  give  the  last  dose  at  least  an  hour  before 
bedtime  and  then  to  repeat  the  same  after  retiring  if  it  is  found  that 
relief  has  not  been  obtained,  and  that,  on  account  of  the  continued 
tinnitus,  sleep  is  impossible.  Should  the  bromids  fail  to  give  relief 
or  should  relapse  occur  during  their  administration,  the  dilute  hydro- 
bromic acid  may  be  tried  in  doses  of  from  J  to  i  dr.,  freely  diluted  with 
water.  In  the  worst  cases,  when  it  is  found  that  the  preceding  remedies 
are  powerless,  and  the  patient  is  becoming  exhausted  from  worry  and 
the  loss  of  sleep,  it  is  sometimes  advisable  to  try  more  powerful  sedatives 
or  hypnotics,  as  chloral  hydrate  or  morphin.  These  latter  drugs 
should,  however,  be  employed  only  as  a  matter  of  urgent  necessity  and 
should  be  withdrawn  just  as  soon  as  they  have  produced  a  temporary 
rest  for  the  patient.  It  should  be  borne  in  mind  that  dangerous 


CHRONIC   NON-SUPPURATIVE    OTITIS   MEDIA  501 

drug-habits  may  be  easily  induced  by  indiscriminate  employment  of 
these  powerful  remedies  for  the  relief  of  tinnitus  aurium.  When 
medicinal  means  fail  to  relieve  the  tinnitus  and  the  patient's  life  is 
made  miserable  by  the  continued  head  noises,  surgical  interference 
should  be  instituted  and  is  under  such  circumstances  entirely  justi- 
fiable. 

In  cases  where  it  has  been  determined  by  means  of  a  functional 
examination  of  the  ear  that  a  labyrinthine  complication  coexists  the 
internal  or  hypodermic  administration  of  pilocarpin  hydrochlorate 
proves  serviceable  in  some  cases,  and  its  use  is,  therefore,  worthy  of  trial. 
Of  course,  the  effect  is  much  more  certain  when  given  by  the  hypodermic 
method,  and  hence  this  should  be  the  rule  of  practise,  especially  when 
the  patient  is  too  ill  to  leave  the  house  or  if  his  business  will  permit  him 
to  remain  at  home  and  in  doors  for  a  few  days.  The  best  results  will  be 
obtained  from  this  drug  when  there  is  present  in  the  labyrinth  an  in- 
creased tension  due  either  to  an  exudate  or  to  pressure  from  the  foot- 
plate of  the  stapes,  as  a  result  of  the  deposit  of  new  tissue  in  the  pelvis 
ovalis.  The  profuse  sweating  which  results  from  the  pilocarpin  favors 
more  or  less  absorption  of  the  intralabyrinthine  contents;  the  pressure 
irritation  upon  the  perceptive  nerve-endings  is  thereby  lessened  and  the 
tinnitus  and  loss  of  function  are  in  some  measure  thereby  restored.  In 
cases  where  it  is  practicable  to  administer  this  drug  hypodermically 
this  should  be  done  once  or  twice  a  day,  beginning  with  the  subcutaneous 
injection  of  y1^,  f ,  or  £  gr.,  according  to  the  age  and  weight  of  the  patient. 
It  is  often  found  necessary  to  increase  the  dosage  in  order  to  secure  the 
full  physiologic  effect  in  the  way  of  profuse  sweating.  When  it  is 
impossible,  on  account  of  business  or  social  duties,  for  the  patient  to 
remain  constantly  indoors  during  the  period  of  treatment,  one  hypo- 
dermic injection  of  the  pilocarpin  may  be  given  at  bedtime,  and  next 
morning  £  or  J  gr.  may  be  taken  by  mouth  immediately  on  awakening, 
so  that  the  period  of  sweating  may  be  passed  before  the  patient  must 
leave  the  house.  Strychnin  sulphate  administered  by  the  mouth  in  doses 
of  -fQ  gr.  three  times  a  day  is  valuable  in  those  cases  which  are  complicated 
by  labyrinthine  disease  without  evidence  of  intralabyrinthine  pressure. 
This  drug  acts  as  a  general  tonic  as  well  as  a  local  stimulant  to  the 
acoustic  nerve  and  its  terminal  endings  in  the  organ  of  Corti.  The  full 
effect  of  this  drug  upon  the  ear  is  often  observed  only  after  its  admin- 
istration has  been  continued  uninterruptedly  for  a  period  of  six  or  eight 
weeks.  It  should  then  be  intermitted  for  three  or  four  weeks  and  again 
repeated  as  before. 

The  influence  of  climate  upon  the  adhesive  processes  of  the  middle 


502  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

ear  after  the  disease  is  well  advanced  is  never  marked  and  is  usually  nil.1 
It  is,  therefore,  seldom  wise  to  recommend  a  change  in  this  respect  unless 
the  disease  of  the  ear  is  only  a  complication  of  some  general  ailment,  as, 
for  example,  of  pulmonary  tuberculosis.  In  the  earlier  stages  of  the 
aural  disease,  however,  when  nasal  and  nasopharyngeal  affections 
continue  to  act  as  exciting  causes  of  the  aural  affection,  a  change  of  resi- 
dence from  a  low,  damp,  and  cold  region  to  one  which  is  warmer,  dryer, 
and  more  elevated,  is  undoubtedly  beneficial.  It  should  be  the  rule  that 
before  such  patients  are  sent  to  a  different  climate  to  remove  any  adenoid, 
nasal  tumor,  or  other  obstructing  growth  of  the  upper  air  passages,  since 
the  climatic  effect  upon  the  ear  will  be  much  more  beneficial  if  the 
environment  of  the  ear  is  free  from  both  obstruction  and  inflammation. 

1  Black,  of  Denver,  Trans.  Soc.  Laryngol.  and  Otol.,  A.  M.  A.,  1898,  states  that  in 
his  experience  non-suppurative  inflammation  of  the  middle  ear  is  as  liable  to  progression 
in  Colorado  as  elsewhere,  and  that  patients  have  frequently  stated  that  their  deafness 
had  markedly  progressed  since  coming  to  that  dry  and  moderately  elevated  region. 


CHAPTER  XLI 

CHRONIC  NON-SUPPURATIVE  OTITIS  MEDIA  (Continued) 

TREATMENT    BY    SURGICAL   MEANS 

SINCE  the  pathology  of  this  affection  is  of  such  nature  that  an  arrest 
or  cure  of  the  disease  through  mechanical  or  medicinal  means  is  seldom 
or  never  effected,  and  since  the  power  of  audition  finally  becomes 
markedly  lessened  while  at  the  same  time  the  tinnitus  aurium  becomes 
incessant  and  intolerable,  relief  from  the  condition  by  surgical  means 
has  been  advocated  and  practised  by  many  otologists.  Unfortunately, 
the  very  excellent  results  that  have  been  reported  by  Sexton  and  others 
have  not  been  secured  by  other  operators,  for,  with  few  exceptions,  the 
cases  that  have  been  treated  by  surgical  measures  have  usually  resumed 
their  former  condition  after  a  short  time  or  have  actually  grown  worse  in 
many  instances. 

Many  of  the  absolute  failures  which  have  followed  surgical  pro- 
cedures upon  the  conducting  apparatus  have  probably  been  due  to  the 
fact  that  the  cases  were  not  properly  selected.  It  is  evident  that  in  cases 
where  there  is  a  coexisting  labyrinthine  affection  of  marked  degree  that 
any  operation  directed  to  the  removal  of  obstruction  to  the  sound-waves, 
which  may  exist  in  the  conducting  mechanism,  could  not  result  in  benefit 
to  the  hearing.  On  the  other  hand,  if  the  perceptive  portion  of  the  ear 
remains  unimpaired;  if  the  obstruction  which  exists  to  the  passage  of 
sound-waves  can  be  successfully  removed,  and  the  sound  impulses  be 
thereby  more  freely  admitted  to  the  perceptive  organ,  some  improvement 
of  hearing  and  relief  from  the  tinnitus  should  be  anticipated  as  a  result  of 
the  removal  of  such  obstruction.  It  is,  therefore,  highly  essential  in  all 
cases  where  operative  measures  are  contemplated  for  the  relief  of  deaf- 
ness due  to  obstruction  in  the  conducting  apparatus  to  ascertain  posi- 
tively beforehand  what  damage,  if  any,  has  been  done  by  the  disease  to 
the  inner  ear  or  the  perceptive  portion  of  the  organ  of  hearing,  and  to 
avoid  operations  upon  the  drum  membrane  or  ossicles  in  the  event  that 
perception  by  bone  conductions  is  found  greatly  impaired.  Chief 
dependence  in  ascertaining  whether  or  not  nerve  deafness  is  present 
must  be  placed  upon  the  results  of  a  carefully  conducted  functional 

503 


504  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

examination  (see  p.  193).  The  various  operations  that  have  been  ad- 
vised and  practised  for  the  relief  of  chronic  catarrhal  otitis  media  have 
for  their  object  the  relief  of  tension  in  the  membrana  tympani  or  the 
ossicular  chain,  and  through  these  the  increased  tension  within  the 
labyrinth.  The  operations  may  be  classed  as  incomplete  and  complete 
or  radical.  Among  the  former  may  be  placed  multiple  incision  of  the 
drum  membrane,  division  of  the  anterior  ligament  of  the  malleus,  incision 
of  the  posterior  fold,  division  of  the  tendon  of  the  tensor  tympani  muscle, 
and  partial  excision  of  the  drum-head.  The  radical  operation  consists 
in  the  complete  removal  of  the  drum-head  together  with  the  malleus  and 
incus  and  of  the  adventitious  tissues  that  have  been  deposited  in  the 
tympanic  cavity  during  the  progress  of  the  chronic  catarrh.  The  more 
radical  operation  also  frequently  includes  the  incision  of  the  adhesive 
structures  which  fill  the  pelvis  ovalis  and  cover  the  foot-plate  of  the 
stapes,  and  rarely  includes  also  the  removal  of  this  ossicle.  Since  all  of 
the  incomplete  operations  remedy  only  a  part  of  the  aural  defect,  and 
usually  not  the  most  essential  part,  this  class  of  aural  surgery  is  seldom 
either  immediately  or  ultimately  successful.  It  can  be  employed,  there- 
fore, only  in  carefully  selected  cases  and  is  seldom  to  be  advised. 

Multiple  incisions  of  the  drum  membrane  have  been  recommended 
by  Gruber  (Lehrbuch  der  Ohrenheilkunde,  S.  259)  for  the  purpose  of 
correcting  overtension  of  this  structure  when  the  same  has  been  pro- 
duced by  the  process  of  deposit  and  subsequent  organization  of  con- 
nective tissue  in  the  tympanic  cavity.  This  author  advocates  the 
incision  of  the  drum-head  in  four  or  more  places,  the  direction  and 
location  of  the  cuts  being,  of  course,  governed  by  the  position  and 
character  of  the  fibrous  bands  which  are  causing  the  increased  tension. 
Generally,  the  incisions  should  radiate  from  the  umbo  toward  the 
tympanic  ring  and,  when  necessary,  other  incisions  may  be  made  at 
right  angles  to  the  first,  and  connecting  one  with  another.  Sexton 
states1  that  as  many  as  fifty  such  incisions  may  be  made  in  a  drum 
membrane  without  injury  and  even  to  the  improvement  of  function. 

The  after-treatment  consists  in  drying  the  auditory  meatus  by,  first, 
the  removal  of  any  collection  of  blood,  and  of  the  subsequent  insertion 
down  to  the  fundus  of  a  wick  of  sterile  gauze.  Catheter  inflation  should 
be  performed  on  the  second  day  and  should  be  repeated  every  forty- 
eight  hours  for  a  period  of  ten  days  or  two  weeks.  The  wounds  in  the 
membrana  tympani  quickly  heal  unless  infection  occurs,  but,  unfortu- 
nately, whatever  improvement  may  have  taken  place  as  a  result  of 
the  relief  of  tension  usually  subsides  along  with  the  closure  of  the 

1  System  of  Diseases  of  Ear,  Nose,  and  Throat,  vol.  i.,  p.  367. 


CHRONIC   NON-SUPPURATTVE   OTITIS   MEDIA  505 

incision.  It,  therefore,  frequently  happens  that  the  ultimate  result  is  a 
worse  condition  of  the  ear,  both  as  to  function  and  subjective  noises, 
than  existed  before  the  incisions  were  made. 

Partial  excision  of  the  drum-head  is  only  one  step  further  toward 
the  radical  intratympanic  operation,  and  consists  in  an  effort  to  secure 
a  permanent  perforation  through  this  thickened,  calcined,  and  immovable 
structure,  the  object  being  to  provide  for  the  admission  of  the  sound- 
waves more  directly  to  the  perceptive  portion  of  the  auditory  apparatus. 
The  site  chosen  for  making  the  window  through  the  drum-head  is  the 
postero-inferior  quadrant,  for  the  reason  that  no  important  structures  lie 
within  the  cavity  of  the  middle  ear  at  this  point.  Much  difficulty  is 
experienced  in  permanently  maintaining  any  opening  after  it  is  once 
made,  the  tendency  on  the  part  of  nature  being  to  rapidly  close  the 
perforation  with  cicatricial  tissue.  The  opening  may  be  made  by  turning 
down  and  excising  a  flap  of  membrane  over  the  area  shown  in  Fig.  297, 
or  the  perforation  can  be  established  by  means  of  either  a  corrosive 
chemical  or  by  the  direct  application  of  the  electrocautery.  When  a 
chemical  agent  is  chosen  for  this  purpose  a  drop 
of  pure  nitric  acid  is  saturated  with  cocain  crys- 
tals. A  slender  aural  applicator  is  selected,  its  tip 
is  covered  by  a  small  pledget  of  cotton,  and  this  is 
clipped  into  the  acid-cocain  solution.  Before  it  is 
used  this  tip  is  touched  to  a  piece  of  blotting-paper 
to  absorb  any  excess  of  acid  and  thus  to  safeguard 
against  spreading  of  the  acid  beyond  the  part  to  FIG.  297.— EXPLORATORY 

i  ff      ,     i         x-r     i  j    -n          •       *•  ^1  'j    •         OPERATION  OVER  AREA  OF 

be  affected.  Under  good  illumination  the  acid  is  IN.CUDOSTAPEDIALART,CU- 
carried  to  the  spot  on  the  membrane  which  it  is  LATKMJ. 

.      .  Showing  a    flap  of    the 

desired  to  perforate,  and  it  is  pressed  firmly  upon  merabrana  tympani  turned 
the  same  until  the  acid  corrodes  the  tissue  and  do™-  same  case  as  shown 

in  Fig.  282. 

permits  the  entrance  of  the  applicator  into  the 
middle  ear.  If  the  electrocautery  is  chosen  the  platinum  tip  of  the 
electrode  is  inserted  against  the  membrane  before  the  current  is  turned  on. 
When  the  tip  is  in  contact  the  circuit  is  made,  when,  if  the  instrument 
has  been  previously  tested  and  the  reostat  set  so  that  the  tip  of  the 
electrode  will  be  at  cherry-red  heat,  the  opening  through  the  membrane 
is  made  almost  instantaneously.  When  using  either  of  the  above  methods 
the  operator  must  be  cautious  not  to  injure  the  structures  within  the 
tympanic  cavity.  One  chief  value  of  partial  excision  of  the  membrana 
tympani  is  that  through  this  procedure  it  is  possible  to  determine  the 
effect  upon  the  hearing  that  results  from  the  free  admission  of  sound- 
waves to  the  foot-plate  of  the  stapes.  It  may,  therefore,  be  looked 


506  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

upon  somewhat  as  a  diagnostic  measure  and  one  which  is  prelimi- 
nary in  suitable  cases  to  the  performance  of  some  more  radical 
procedure. 

Division  of  the  posterior  fold,  sometimes  called  plicotomy,  is 
now  and  then  made  for  the  purpose  of  relieving  the  subjective  noises  and 
improving  the  hearing.  The  operation  is  indicated  when  the  fold  is 
unduly  prominent  and  sharp,  forming  a  sickle-shaped  ridge  between  the 
short  process  and  the  annulus  (see  Fig.  287),  since  the  condition  is  found 
in  cases  where  there  is  great  retraction  of  the  drum  membrane  with  re- 
sulting increase  of  tension.  The  operation  may  be  performed  by  means 
of  the  paracentesis  knife  (Fig.  141),  the  division  of  the  fold  being  made 
a  short  distance  posterior  to  the  short  process  of  the  malleus.  It  should 
be  borne  in  mind  that  the  chorda  tympani  nerve  lies  just  within  this  fold 
(see  Fig.  297),  and  the  operator  will,  therefore,  avoid  injuring  it,  if  pos- 
sible, by  not  cutting  more  deeply  than  is  necessary.  However,  it  has 
been  elsewhere  stated  that  division  of  this  nerve  results  in  nothing  more 
serious  than  a  temporary  loss  of  taste  on  that  side  of  the  tongue  which 
corresponds  to  the  wounded  nerve.  No  after-treatment  is  necessary 
further  than  the  insertion  of  a  sterile  gauze  wick  into  the  external  auditory 
meatus,  and  the  performance  of  catheter  inflation  on  alternate  days  for 
a  period  of  two  weeks.  The  result  of  the  division  of  the  posterior  fold 
depends  upon  whether  or  not  the  intratympanic  structures  are  or  are  not 
immovably  fixed.  If  the  ossicular  chain  is  not  ankylosed  and  if  no 
adhesions  exist  between  the  drum  membrane  and  the  tympanic  walls, 
marked  improvement  may  result.  Politzer1  states  that  this  improve- 
ment is  not  permanent  and  that  after  several  months  have  elapsed  the 
former  condition  of  the  ear  is  resumed. 

Tenotomy  of  the  tensor  tympani  muscle  was  first  performed  by 
Weber-Liel  in  1868,  since  which  time  it  has  been  employed  by  many 
otologists.  The  indication  for  the  division  of  the  tendon  of  this  muscle 
is  based  upon  the  assumption  that  the  cause  of  the  greatly  retracted 
drum  membrane,  together  with  the  symptoms  of  deafness  and  tinnitus 
aurium,  is  due  largely  or  wholly  to  a  contracted  state  of  the  tensor 
tympani  muscle.  Since  in  chronic  non-suppurative  catarrh  of  the 
middle  ear  other  pathologic  conditions,  in  the  form  of  organized  new 
tissues,  are  present  which  bind  the  ossicular  chain  and  membrana 
tympani  into  an  immovable  mass,  it  must  be  clear  that  a  mere  division 
of  the  tendon  of  the  tensor  tympani  muscle  will  not  effect  a  restoration 
of  the  structures  of  the  conducting  apparatus  to  either  their  normal 
position  or  to  a  normal  state  of  mobility.  The  principle  of  the  operation 

1  Diseases  of  the  Ear,  p.  306. 


CHRONIC   NON-SUPPURATIVE   OTITIS   MEDIA  507 

is,  therefore,  based  upon  a  false  assumption,  and  the  results  of  its  per- 
formance have  not  been  such  as  to  commend  it  to  further  use. 

Under  the  section  which  treats  of  the  pathology  of  this  disease  it 
has  been  shown  that  as  the  affection  advances  the  deposit  of  new 
tissues  takes  place  in  the  tympanic  cavity  and  membrana  tympani, 
and  that  ultimately  the  whole  conducting  apparatus  may  become  so 
immovably  fixed  as  to  provide  an  actual  obstruction  rather  than  an 
ideal  means  of  conduction  to  the  passage  of  sound-waves.  It  is  evident, 
therefore,  that  none  of  the  foregoing  operations  which  are  intended 
for  the  correction  of  only  one  of  the  actual  conditions  present  in  this 
conducting  apparatus,  will  prove  sufficient  to  overcome  in  more  than 
a  slight  degree  the  real  difficulty.  Hence,  when  surgical  intervention 
is  determined  to  be  the  proper  procedure  in  this  class  of  cases,  it  is 
usually  wise  to  attack  the  diseased  structures  in  a  radical  manner  and 
to  remove  the  whole  membrana  tympani,  together  with  the  malleus 
and  incus. 

The  lechnic  of  this  operation  consists  in  first  sterilizing  the  external 
auditory  meatus  and  then  securing  anesthesia  either  through  the 
administration  of  a  general  anesthetic  or  by  the  application  of  cocain 
directly  to  the  field  of  operation.  The  rules  governing  the  employment 
of  the  one  or  the  other  method  of  anesthesia  are  given  on  p.  245.  The 
following  addition  should,  however,  be  made  to 
what  is  there  said  concerning  cocain  anesthesia: 
The  membrana  tympani,  in  all  cases  of  dry  middle- 
ear  catarrh  in  which  operative  measures  are  indi- 
cated, is  intact  and  often  greatly  thickened.  Anes- 
thesia of  the  operative  field  by  the  local  applica- 
tion of  cocain  is,  therefore,  impossible  until  an 
opening  of  sufficient  extent  has  been  made  through 

FIG.  298. — LINES  OF  IN- 

this  membrane  to  admit  the    anesthetic   solution     CISION    THROUGH   MEM- 

.    ,       ,,  .     .j       r  ,1  ...  BRANA  TYMPANI  IN  Ossic- 

mto  the  cavum  tympani.     Aside  from  the  position     ULECTOMY- 

of  the  patient,  which  is  erect  during  the  operation 

under  local  anesthesia  and  semireclining  under  the  general  anesthetic, 

the  steps  of  the  operation  by  either  method  are  exactly  the  same. 

With  the  delicate,  sharp-pointed  knife  (see  Fig.  141)  an  incision  is 
made  through  the  tympanic  membrane  in  the  position  and  to  the  extent 
shown  by  the  dark  line  AB  in  Fig.  298.  A  probe-pointed  knife  (see 
Fig.  218)  is  then  substituted,  and  the  cut  is  carried  upward  to  the  pos- 
terior fold,  thence  forward  along  this  fold  to  the  short  process,  thence 
downward  along  the  manubruim  to  near  the  umbo,  the  whole  incision 
following  the  course  shown  by  the  dotted  line  in  Fig.  298.  The  flap 


508  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

thus  provided  is  turned  down  (as  shown  in  Fig.  297)  and  the  site  of  the 
incudostapedial  articulation  is  thus  exposed.  If  care  has  been  exercised 
when  using  the  sharp-pointed  knife  for  making  the  initial  incision  not 
to  insert  it  too  deeply  and  thereby  wound  the  mucous  lining  of  the 
middle  ear,  and  if  the  subsequent  course  of  the  probe-pointed  knife  is 
not  continued  too  near  the  annulus  tympanicus,  but  very  slight  or 
possibly  no  bleeding  will  result  from  this  part  of  the  operation  and, 
consequently,  the  contents  of  the  exposed  portion  of  the  middle  ear 
will  be  clearly  visible.  Division  of  the  stapedius  muscles  constitutes 
the  next  step,  which  is  accomplished  by  passing  the  sharp-pointed  knife 
above  and  posterior  to  the  head  of  the  stapes,  pressing  it  firmly  inward 
against  the  osseous  tympanic  wall,  and  then  cutting  downward  until  the 
tendon  is  severed.  Immediately  following  the  division  of  the  tendon  of 
the  stapedius  the  head  of  the  stapes  should  be  disarticulated  from  the 
long  process  of  the  incus,  which  step  is  performed  by  inserting  the 
angular  knife  between  the  long  processes  of  the  hammer  and  incus 
to  such  a  depth  that  when  the  handle  of  the  knife  is  rotated  back- 
ward the  angular  blade  will  fall  into  a  position  internal  to  the  long 
process  of  the  incus,  which  latter  process  the  blade  of  the  knife  should 
be  caused  to  hug,  following  it  downward  as  a  guide  until  the  joint 
is  reached  and  severed  by  the  cutting  edge. 

Following  the  disarticulation  of  the  stapes  and  incus  the  probe- 
pointed  knife  is  again  inserted  below  X  (Fig.  297)  and  carried  around 
the  umbo  to  the  anterior  border  of  this  process,  and  upward  as  far  as 
the  short  process  of  this  ossicle.  The  knife  can  then  either  be  continued 
along  the  anterior  fold,  first  to  the  annulus,  and  following  this  in  the 
clear  membrane  to  point  B,  the  beginning,  or  it  may  be  withdrawn 
when  the  annulus  is  reached  and  reinserted  at  point  B,  the  reverse  course, 
B,  X"  to  X,  being  followed  (Fig.  297).  In  either  case  the  whole  mem- 
brana  vibrans  is  thus  detached  and  can  be  removed.  Should  any  bleeding 
occur,  pressure  upon  the  bleeding  areas  may  now  be  made  by  the  inser- 
tion into  the  fundus  of  a  cylinder  of  cotton  saturated  with  adrenalin 
chlorid,  which  is  allowed  to  remain  for  a  moment,  or  until  the  hemorrhage 
is  arrested.  The  next  step  consists  of  the  division  of  the  anterior  and 
posterior  ligaments  of  the  malleus,  which  is  accomplished  by  the  insertion 
of  the  sharp-pointed  knife,  first,  just  posterior  to  the  short  process  of 
the  malleus  and  then  anterior  to  this  process,  and  in  each  instance 
pushing  the  blade  inward  to  the  internal  osseous  wall,  and  then  de- 
pressing the  handle  to  such  a  degree  as  to  cause  the  blade  to  rise  suffi- 
ciently to  completely  sever  the  respective  ligaments.  If  thought  de- 
sirable the  tendon  of  the  tensor  tympani  may  be  next  divided,  but 


CHRONIC   NON-SUPPURATIVE    OTITIS    MEDIA  509 

usually  this  is  unnecessary  since  this,  together  with  the  suspensory, 
external,  and  annular  ligaments,  the  only  remaining  supports  of  the 
ossicle,  readily  yield  to  the  slight  force  which  is  subsequently  necessary 
to  withdraw  the  bone  by  traction.  The  ossicle  is,  therefore,  at  once 
seized  by  its  neck  between  the  jaws  of  a  strong,  though  delicate  forceps 
(see  Fig.  219),  upon  which  traction  is  first  made  in  an  inward  and  down- 
ward direction  until  the  ossicle  is  dislocated  into  the  atrium,  after  which 
it  is  withdrawn  through  the  external  meatus. 

Because  of  its  ligamentous  attachment  to  the  incus  the  removal 
of  the  malleus  by  traction  usually  dislodges  the  former  ossicle  from  its 
normal  position,  and  hence  when  it  is  subsequently  sought  for  it  is 
often  found  to  have  been  dragged  downward  and  backward,  and  to 
occupy  a  position  in  the  postero-inferior  quadrant  of  the  tympanic 
cavity.  If  any  portion  of  the  bone  can  be  seen  in  either  a  normal  or 
abnormal  position,  the  same  should  be  seized  by  the  forceps  and  the 
ossicle  at  once  be  withdrawn.  In  case  the  ossicle  cannot  be  seen  it 
becomes  necessary  to  search  for  it,  bring  it  into  view,  and  then  remove 
it.  For  the  purpose  of  bringing  this  ossicle  into  view  when  once  it  has 
been  dislocated  and  lost,  the  incus  hooks,  right  and  left  (see  Fig.  220), 
must  be  used.  One  of  these,  the  convexity  of  whose  curved  extremity 
looks  backward,  is  selected  and  is  inserted  into  the  tympanum  beyond 
the  tympanic  ring  and  with  its  convexity  lying  upon  the  floor  of  the 
middle  ear.  The  instrument  is  then  withdrawn  until  the  outer  surface 
of  the  angular  hook  hugs  the  adjoining  portion  of  the  tympanic  ring. 
In  this  position  rotation  of  the  handle  of  the  hook  is  made,  beginning 
with  the  concavity  of  the  hook  looking  upward,  and  continuing  until 
the  hook  has  made  a  complete  circuit  of  the  tympanic  cavity,  and, 
therefore,  ends  with  the  concavity  of  the  hook  looking  downward. 
Throughout  the  entire  circuit  of  the  hook  around  the  tympanic  cavity 
it  should  be  held  so  that  it  constantly  hugs  the  tympanic  ring.  It 
will  be  obvious  that  when  search  is  made  for  the  incus  by  using  the  incus 
hook  after  the  method  just  described  that  it  would  be  impossible  to 
dislodge  the  ossicle  backward  into  the  mouth  of  the  aditus  ad  antrum, 
an  accident  which  it  is  desirable  to  avoid.  However,  if  the  incus  is  not 
found  by  this  first  hook,  the  one  of  opposite  curvature  should  be  used 
to  explore  the  cavity  of  the  middle  ear  in  an  exactly  opposite  direction 
to  that  just  described.  By  carefully  following  these  rules  for  extraction 
it  is  scarcely  possible  not  to  bring  the  ossicle  into  such  position  that  it 
can  be  clearly  seen  and  easily  removed  by  the  forceps. 

After  drying  away  any  blood  that  has  again  collected  in  the  auditory 
meatus  and  middle  ear,  it  is  usually  possible  to  see  the  head  and  at  least 


510  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

a  portion  of  the  crura  of  the  stapes.  An  examination  of  this  ossicle 
constitutes  the  next  consideration,  since  it  is  important  to  know  whether 
or  not  it  is  movable  or  is  fixed  by  adhesive  bands  of  connective  tissue 
running  between  the  crura  and  adjacent  walls  of  the  pelvis  ovalis,  or  pos- 
sibly by  the  deposit  of  fibrous  tissue  about  the  foot-plate  in  the  oval 
window.  These  facts  may  be  ascertained  by  means  of  a  delicate,  though 
resisting,  cotton-tipped  applicator,  which  is  pressed  firmly  against  the 
head  of  the  bone  from  all  sides,  while  at  the  same  time  it  is  noted  whether 
or  not  any  movement  of  the  ossicle  results  therefrom.  Should  the  ossicle 
be  found  to  be  immovably  bound  down  and  the  position  of  the  pelvis 
ovalis  can  be  seen  with  sufficient  clearness,  the  attempt  may  be  made  to 
mobilize  it  by  severing  the  adhesive  bands  which  hold  it  in  place.  This 
may  be  accomplished  by  passing  the  sharp-pointed  knife  around  the 
crura  of  the  stapes  and  to  a  depth  corresponding  to  the  annular  ligament 
of  the  foot-plate.  The  whole  ossicle,  with  the  exception  of  a  portion  of 
the  foot-plate,  having  thus  been  liberated,  a  delicate  hook  is  inserted 
between  the  crura  by  means  of  which  a  rocking  motion  is  given  to  the 
ossicle  to  insure  its  complete  mobilization.  It  is  seldom  necessary  or 
justifiable  to  remove  the  stapes,  for  the  reason  that  if  it  be  properly 
mobilized  equally  good  results  will  follow  and  labyrinthine  suppuration 
is  a  possibility  after  its  extraction. 

The  after-treatment  consists  in  the  insertion  into  the  middle  ear  of 
a  strip  of  sterile  or  borated  gauze  which  should  loosely  fill  the  middle  ear 
and  external  auditory  meatus.  Several  thick  pads  of  gauze  are  placed 
over  the  concha  and  external  ear  and  the  dressing  is  completed  by  the 
application  of  a  roller  bandage  (Fig.  225).  This  dressing  may  be 
allowed  to  remain  for  one  or  more  days,  according  to  whether  or  not  it 
becomes  soiled  or  whether  or  not  pain  occurs  of  sufficient  severity  to 
necessitate  an  earlier  change.  If  the  antiseptic  technic  at  the  time  of  the 
operation  has  been  perfect  and  the  subsequent  treatment  is  carried  out 
with  equal  care  as  to  cleanliness,  suppuration  during  the  process  of 
epidermization  of  the  exposed  drum  cavity  may  be  avoided.  Since, 
however,  the  continuance  of  an  ideal  technic  is  seldom  possible,  infection 
sometimes  takes  place,  suppuration  results,  and  the  treatment  should 
then  be  upon  the  plan  of  that  advised  for  an  acute  purulent  otitis  media 
(see  Chapter  XXIII.). 

The  results  of  the  operation  will  depend  much  upon  the  diagnostic 
care  with  which  the  cases  are  selected  and  upon  the  skill  with  which  the 
obstructive  tissues  are  removed.  No  improvement  will  result  in  any 
operated  case  in  which  the  obstruction  to  the  conducting  apparatus  is 
seriously  complicated  by  labyrinthine  affection.  In  other  words,  the 


CHRONIC   NON-SUPPURATIVE   OTITIS   MEDIA  511 

more  purely  the  case  is  one  of  defect  due  to  hindrance  of  the  passage  of 
sound-waves  through  the  middle  ear,  the  better  the  results  of  intratym- 
panic  surgery  are  likely  to  be.  It  may  be  stated  that  in  the  main  the 
very  favorable  results  that  were  obtained  by  earlier  operators1  are  not 
secured  by  all  those  at  present  engaged  in  the  practise  of  operative 
otology.  Among  the  latter  it  should  be  stated,  however,  that  Dench  has 
maintained  in  a  commendable  way  the  record  established  by  Sexton  and 
others.2 

It  has  usually  been  found  that  even  those  who  were  most  favorably 
affected  immediately  after  this  operation  have  ultimately  resumed  their 
former  condition,  and  in  many  instances  even  a  worse  state  than  before 
the  ossiculectomy  was  performed.  In  all  cases  there  is  a  tendency 
toward  the  re-formation  of  the  drum  membrane  and  in  a  few  months 
its  regeneration  is  often  complete.  When  this  occurs  the  hearing  again 
becomes  worse  and  it  is  necessary  a  second,  and  even  a  third  time,  to 
excise  the  regenerated  part.  Each  newly  formed  membrane  is,  how- 
ever, found  to  be  thinner  and  more  insensible  than  its  predecessor  and 
its  excision  becomes,  therefore,  a  more  increasingly  trivial  matter. 

Otosclerosis. — This  name  has  been  given  to  a  form  of  progressive 
middle-ear  deafness  which  closely  simulates  that  of  adhesive  catarrhal 
deafness  in  every  particular  except  the  pathology.  In  many  cases  of 
otosclerosis  the  tympanic  mucous  membrane  and  the  membrana  tympani 
are  absolutely  normal,  the  sole  pathologic  change  being  found  in  the 
pelvis  ovalis,  around  the  foot-plate  of  the  oval  window,  and  in  the  laby- 
rinthine capsule.  The  chief  pathologic  feature  of  the  disease,  there- 
fore, consists  in  a  deposit  of  osseous  tissue  on  the  promontory  and  walls 
of  the  pelvis  ovalis,  whereby  the  niche  of  the  oval  window  is  more  or  less 
obliterated  and  in  and  around  the  foot-plate  of  the  stapes,  with  the 
result  that  the  stapes  becomes  immovably  fixed  in  the  oval  window 
(Figs.  299  and  300). 

This  osseous  deposit  may  be  in  sufficient  amount  to  greatly  thicken 
the  foot-plate,  to  obliterate  its  ligament,  and  to  extend  to  the  adjacent 
capsule  of  the  labyrinth.  In  such  instance  all  lines  representing  the 
articular  boundary  of  this  ossicle  in  the  oval  window  are  obliterated, 

1 "  The  results  of  the  operation  have,  in  the  author's  experience,  been  most  gratifying. 
Not  only  is  a  stop  put  to  the  progress  of  the  disease,  but  the  hearing  power  usually  shows 
an  increase,  which,  in  some  instances,  is  marked  indeed.  The  tinnitus,  too,  usually 
disappears  altogether." — Samuel  Sexton  in  Burnett's  System  Ear,  Nose,  and  Throat,  1893. 

2  "  Of  cases  where  the  membrana  tympani  was  intact,  including  one  or  two  instances 
in  which  there  had  been  a  suppurative  process  in  childhood,  with  complete  closure  of 
the  perforation,  90  have  been  subjected  to  operation.  Of  these  there  was  much 
improvement  in  78  cases,  10  were  unimproved,  i  grew  worse  after  operation,  and  in  i  the 
result  was  unknown." — Dench,  Diseases  of  the  Ear,  1903. 


512  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

and  this  portion  of  the  bone  is  completely  amalgamated  and  buried,  so 
to  speak,  by  the  deposit  of  the  adventitious  osseous  tissue  (Fig.  300). 
The  recess  of  the  round  window  is  also  sometimes  encroached  upon, 


FIG.  299. — DEPOSIT  OF  OSSEOUS  TISSUE  UPON  THE  FOOT-PLATE  AND  CRUS  or  THE  STAPES,  CAUSING  PAR- 
TIAL ANKYLOSIS  OF  THE  OSSICLE  IN  THE  OVAL  WINDOW.     (After  Politzer.) 

with  the  result  that  it  becomes  greatly  narrowed  or,  perhaps,  entirely 
obliterated. 


FIG.  300. — SHOWING  OBLITERATION  OF  THE  OVAL  WINDOW  AND  PARTIAL  FILLING  OF  THE  PELVIS  OVALIS 

BY  THE  DEPOSIT  OF  NEW  OSSEOUS  TISSUE. 

The  stapes  is  almost  submerged  by  the  deposit  and  its  foot-plate  and  a  portion  of  the  crura  are  amalgamated 
with  the  surrounding  structure.     (After  Politzer.) 

The  Causation  of  Otosderosis. — As  factors  in  the  production  of  this 
disease  hereditary  syphilis,  faulty  states  of  the  blood,  and  the  age  of  the 


CHRONIC    NON-SUPPURATIVE    OTITIS    MEDIA  513 

individual  may  be  mentioned.  Many  cases  develop  without  any 
assignable  reason.  When  several  members  of  one  family  develop  a  non- 
suppurative  deafness,  and  when  a  catarrhal  tendency  in  such  individuals 
can  be  eliminated,  the  disease  has  been  found  to  be  one  of  otosclerosis 
rather  than  adhesive  middle-ear  catarrh.  Acquired  syphilis  is  one  of 
the  most  frequent  causes  and  the  disease  sometimes  follows  the  hered- 
itary variety.  The  affection  is  most  frequently  found  in  those  past 
middle  life  and,  according  to  some  observers,  occurs  oftener  in  women 
than  in  men. 

Symptoms  and  Diagnosis. — The  subjective  symptoms  are  much  the 
same  as  in  the  adhesive  variety  of  catarrhal  deafness  just  described. 
A  progressive  loss  of  hearing  is  a  most  constant  symptom,  each  year  the 
patient  becoming  more  and  more  hard  of  hearing  until,  finally,  the 
speaking  voice  is  heard  with  difficulty  or  not  at  all.  While  the  laby- 
rinth remains  unaffected  the  patient  may  continue  to  hear  with 
satisfaction  the  singing  voice  or  the  instrumental  musical  note  long 
after  the  speaking  voice  cannot  be  heard.  In  otosclerosis  the  varying 
conditions  of  the  weather  do  not  exert  as  much  influence  over  the  failing 
powers  of  audition  as  is  the  case  when  a  catarrhal  process  is  the  chief 
causative  agent  of  the  affection.  The  individual  hears  as  well, 
therefore,  in  winter  as  in  summer  and  on  damp  as  well  as  on  bright, 
dry  days.  The  patient  often  hears  better  when  riding  on  a  railway 
train  or  wrhen  in  some  noisy  place  like  a  mill  than  where  all  is  quiet. 
Such  patients  may,  therefore,  be  able  to  carry  on  a  conversation  with 
so  much  ease  under  such  circumstances  that  one  who  is  not  aware  of 
the  deafness  might  not  then  suspect  it,  whereas,  when  all  is  quiet  the 
same  person  is  able  to  hear  only  the  loudest  conversational  tones.1 

Tinnitus  aurium  is  probably  never  absent  in  otosclerosis  and  con- 
stitutes the  symptom  of  which  greatest  complaint  is  usually  made.  The 
head  noises  reach  the  height  of  their  intensity  in  this  particular  disease, 
and  the  patient  is  often  driven  to  the  verge  of  madness  by  the  incessant 
ringing  or  buzzing  in  his  ears.  Except  in  their  greater  intensity,  these 
noises  differ  in  no  respect  from  the  tinnitus  which  accompanies  the 
adhesive  catarrhal  processes.  Pain  is  an  infrequent  symptom  and  is 
present  only  in  the  early  stages  of  the  disease  and  is  never  severe.  Ner- 
vousness and  neurasthenia  finally  occur  as  a  result  of  the  tinnitus;  and 
vertigo,  due  to  increased  labyrinthine  pressure,  is  sometimes  among  the 
symptoms  of  the  fully  developed  disease. 

1  The  ability  of  partially  deaf  individuals  to  hear  better  in  a  noise  is  a  symptom  which 
has  been  described  under  the  name  paracusis  Willisii.     The  ability  to  hear  better  under 
these  circumstances  is  usually  regarded  as  a  symptom  denoting  an  advanced  stage  of 
the  aural  disease  and  one  not  amenable  to  successful  treatment. 
33 


514  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

Objective  Symptoms. — The  membrana  tympani  will  usually  be  seen 
to  occupy  a  normal  position  and  with  all  its  landmarks  clearly  visible. 
Sometimes,  however,  the  tympanic  membrane  is  opaque  and  thickened 
and  calcareous  or  atrophic  areas  may  be  seen  upon  it.  The  external 
auditory  meatus  is  often  narrow,  collapsed  in  the  aged,  and  the  skin 
lining  this  canal  is  abnormally  dry  and  hard.  The  nasopharynx, 
pharynx,  and  nose  are  usually  free  from  obstruction  or  inflammation,  but 
sometimes  an  atrophic  state  of  the  membranous  lining  is  observed  and 
ozena  is  not  infrequently  coexistent  with  the  otosclerosis.  The  naso- 
pharyngeal  orifice  of  the  Eustachian  tube  is  seen  by  postrhinoscopic 
examination  to  be  widely  open  and  the  mucous  structures  about  it  to  be 
pale,  atrophied,  or  of  fibrous  appearance.  Upon  catheter  inflation  it  is 
found  that  the  whole  Eustachian  tube  is  abnormally  patent,  and  the  air 
enters  the  tympanic  cavity  in  great  volume  and  without  hindrance. 

The  diagnosis  will  be  based  upon  the  above  facts  which  are  obtained 
from  the  history  of  the  case,  from  the  physical  examination  of  the  external 
and  middle  ear,  and  of  the  nose,  nasopharynx,  and  Eustachian  tube. 
The  main  facts  upon  which  reliance  in  diagnosis  can  be  placed  are:  The 
history  of  a  progressive  deafness  which  is  accompanied  by  intolerable 
tinnitus  aurium,  in  which  the  deafness  is  but  little  or  not  at  all  affected 
by  climatic  changes;  in  which  heredity  and  not  a  previous  catarrhal 
state  of  the  upper  air  passages  seem  to  form  the  most  rational  explanation 
of  the  disease;  and,  finally,  the  physical  examination,  which  shows  the 
drum  membrane  to  be  normal  and  the  Eustachian  tube  to  be  abnormally 
patent.  In  cases  where  the  drum-head  is  cloudy  and  thickened  and  in 
which  evidences  of  former  inflammatory  states  of  the  respiratory  mucous 
membranes  still  exist,  the  diagnosis  of  otosclerosis  cannot  be  made  with 
certainty.  Instances  of  hereditary  or  acquired  syphilis,  which  are 
accompanied  by  all  or  a  majority  of  the  above  symptoms,  may,  with 
much  certainty,  be  considered  as  diagnostic  of  the  aural  disease  in 
question. 

The  prognosis,  in  the  present  imperfect  state  of  our  knowledge 
concerning  the  treatment  of  otosclerosis,  must  be  considered  most 
unfavorable.  This  is  not  surprising  in  view  of  the  fact  that  the  pathology 
of  the  disease  is  of  such  nature  and  is  in  such  inaccessible  situation  as 
to  render  efficient  treatment  almost  if  not  quite  impossible.  Any 
improvement  that  may  occur  as  the  result  of  treatment  is  likely  to  be  of 
short  duration,  and  the  former  condition  frequently  recurs,  oftentimes 
with  an  increased  severity.  In  a  few  cases  the  head  noises  either  ex- 
haust the  perceptive  centers  for  their  particular  tones  or  else  the  patient 
becomes  accustomed  or  resigned  to  their  presence,  for  in  some  instances 


CHRONIC    NON-SUPPURATIVE   OTITIS   MEDIA  515 

the  patient,  after  a  long  period  of  endurance,  will  cease  to  complain  of 
this  once  intolerable  and  ever-present  symptom. 

Treatment. — Whereas  the  past  few  years  have  witnessed  remarkable 
advances  in  both  the  therapy  and  surgery  of  the  ear.  little  has  been 
accomplished  toward  the  cure  of  otosclerosis,  and  the  otologist  is,  there- 
fore, just  as  helpless  in  the  management  of  this  disease  to-day  as  he  was 
a  generation  ago.  Between  the  years  1885  and  1900,  many  aural 
surgeons  were  busy  perfecting  operative  procedures  whereby  this  disease 
could  be  ameliorated  or  cured.  During  this  time  encouraging  reports 
were  published  concerning  the  results  of  these  operative  measures,  and 
high  hopes  were  expressed  to  the  effect  that  relief  is  possible  through 
surgical  methods  which  removed  or  at  least  mobilized  the  stapes,  since 
the  accomplishment  of  this  end  did  away  with  the  hindrance  to  the 
passage  of  the  sound-waves  through  the  foot-plate  of  the  stapes.  Later 
reports  of  these  same  operators  as  to  the  value  of  otoscleronectomy  show, 
almost  without  exception,  that  the  improvement  which  was  at  first 
brought  about  was  of  a  temporary  nature  and  that  often  the  patient 
was,  as  a  result  of  the  operative  measure,  made  worse  both  as  to  the 
degree  of  deafness  and  the  intensity  of  the  tinnitus. 

In  view  of  the  fact,  however,  that  many  of  these  cases  when  treated 
only  by  medicinal  or  local  means  other  than  surgery,  progress  rapidly 
to  a  high  degree  of  deafness,  and  are  annoyed  beyond  human  endurance 
by  the  distressing  tinnitus  from  which  other  means  of  relief  are  unavailing, 
it  seems  cruel  to  deny  the  patient  even  the  temporary  relief  from  those 
conditions  which  is  sometimes  obtained  by  the  removal  or  mobilization 
of  the  stapes  (see  p.  510).  When  this  operation  is  undertaken  it  should 
be  remembered,  however,  that  it  is  not  always  possible,  because  of  the 
welding  of  the  foot-plate  into  the  oval  window,  which  has  taken  place  as 
the  result  of  the  osseous  deposit  about  it  (Fig.  300),  and  the  consequent 
thickening  of  the  bone  in  this  location,  to  remove  the  foot-plate  without 
running  a  risk  of  great  damage  to  the  labyrinth.  An  infection  of  the 
contents  of  the  vestibule,  with  subsequent  suppuration  of  the  labyrinth, 
occurring  as  the  result  of  unwise  or  unskilful  attempts  to  remove  the 
bony  deposit  in  the  oval  window,  would  result  in  vastly  more  suffering 
to  the  patient  than  would  the  continuance  of  the  original  disease. 

The  inflation  of  the  Eustachian  tube  by  air,  either  plain  or  medicated, 
or  the  injection  of  fluids  into  the  tube,  is  usually  either  entirely  in- 
effective or  even  harmful.  Politzer  states  that  pneumomassage  of  the 
external  auditory  meatus,  practised  in  the  early  stages,  is  capable  of 
bringing  about  good  results.  It  must  be  conceded  that  any  such  method 
when  employed  after  the  stapes  has  become  imprisoned  in  the  oval 


516  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

window  from  the  deposit  of  new  osseous  tissue  will  prove  entirely  in- 
effective and  useless. 

In  the  early  stages,  particularly  if  a  specific  origin  of  the  disease  is 
probable,  the  internal  administration  of  the  iodids  of  sodium  or  potas- 
sium for  a  considerable  period  of  time  has  proved  serviceable.  After 
fixation  of  the  stapes  has  taken  place,  however,  it  is  not  possible  to 
affect  the  course  of  the  disease  by  any  therapeutic  measure. 


CHAPTER    XLII 

DISEASES    OF  THE    PERCEPTIVE    PORTION   OF   THE 
HEARING   APPARATUS 

General  Consideration. — Affections  of  this  portion  of  the  organ  of 
hearing  include  the  vestibule,  semicircular  canals,  cochlea,  auditory 
nerve,  and  the  center  in  the  brain  of  this  special  sense.  This  portion  of 
the  ear  is  commonly  known  as  the  labyrinth,  and  the  diseases  affecting 
it  are,  therefore,  properly  designated  as  labyrinthine. 

Owing  to  its  protected  situation  in  the  depths  of  the  petrous  portion 
of  the  temporal  bone,  disease  of  the  inner  ear  is  much  less  frequently 
observed  than  in  the  tympanic  cavity  and  its  accessory  air  spaces. 
Primary  labyrinthine  affections  are  comparatively  rare,  but  ailments  of 
the  perceptive  apparatus,  occurring  secondary  to  diseases  of  the  middle 
ear,  are  more  common  and  constitute  a  majority  of  the  diseases  of  the 
inner  ear. 

Causation. — Labyrinthine  disorders  are  usually  the  result  of  an 
infection,  which  may  act  either  through  the  general  circulation  or  else 
they  are  of  local  origin  and  extend  inward  from  the  cavity  of  the  middle 
ear  by  way  of  the  oval  or  round  window;  or  the  extension  may  be  out- 
ward from  the  cranial  cavity,  the  infection  finding  its  way  into  the 
labyrinth  through  the  internal  auditory  meatus,  ductus  endolymphat- 
icus  or  aqueductus  cochleae.  Infection  may  also  occur  as  a  result  of 
caries  or  necrosis  of  some  portion  of  the  osseous  labyrinth,  in  which  case 
the  pathogenic  bacteria,  which  are  present  in  the  suppurating  car,  find 
direct  entrance  into  some  portion  of  the  inner  ear.  As  examples  of  in- 
fection and  disease  of  the  labyrinth  occurring  as  the  result  of  a  general 
disease,  the  frequent  aural  complications  of  mumps,  typhoid  fever,  diph- 
theria, etc.,  may  be  cited.  The  auditory  nerve  is  particularly  prone  to 
injury  as  a  result  of  the  presence  in  the  circulation  of  the  morbid  poisons 
of  the  infectious  diseases.  Extension  of  the  morbid  processes  of  the 
middle  ear  due  either  to  suppuration  or  the  deposit  of  non-suppurative 
tissues  is  often  observed.  It  has  already  been  stated  (p.  479)  that  dis- 
ease of  the  perceptive  mechanism  is  a  common  complication  of  chronic 
non-suppurative  middle-ear  catarrh,  and  especially  is  this  true  in  those 
cases  in  which  there  is  fixation  of  the  foot-plate  of  the  stapes  in  the  oval 

517 


518  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

window  as  a  result  of  the  deposit  of  connective  or  osseous  tissue  in  this 
location. 

Certain  neuroses  are  also  at  times  accompanied  by  deafness,  the 
nature  of  which  is  closely  associated  w'th  diseases  of  the  perceptive 
mechanism.  This  condition  is  most  frequently  witnessed  in  individuals 
whose  systems  have  been  weakened  by  prolonged  disease.  No  visible- 
evidence  of  any  aural  affection  can  be  made  out  in  such  cases,  but  the 
hearing  power  is  nevertheless  greatly  impaired,  the  vibrating  tuning-fork 
is  heard  poorly  by  bone  conduction,  and  the  most  reasonable  explanation 
of  the  trouble  lies,  therefore,  in  the  assumption  that  the  acoustic  nerve 
or  its  terminal  filaments  are,  for  the  time  at  least,  so  exhausted  that  they 
are  no  longer  capable  of  normal  response  to  auditory  stimuli. 

Traumatism  is  also  responsible  for  some  cases  of  diseases  of  the 
internal  ear.  The  labyrinthine  affection  which  follows  an  injury  will 
usually  bear  some  relation  to  the  force  and  extent  of  the  injury.  Hence, 
the  resulting  impairment  of  hearing  with  its  accompanying  tinnitus,  and 
possibly  with  vertigo  and  nausea,  may  be  of  a  mild  nature  and  of  short 
duration,  whereas,  if  fracture  of  the  base  of  the  skull  has  occurred,  and 
the  petrous  portion  of  the  temporal  is  involved,  hemorrhage  into  the 
the  labyrinth,  with  subsequent  infection,  may  take  place;  and,  should 
the  patient  survive  long  enough,  suppuration  and  complete  destruction 
of  the  labyrinthine  contents  may  occur.  Injury  to  the  labyrinth 
may  also  follow  the  sudden  and  powerful  condensation  of  air  in  the 
external  meatus,  as,  for  instance,  that  which  takes  place  when  terrific 
explosions  occur  in  close  proximity  to  the  individual.  In  such  instances 
the  foot-plate  of  the  stapes  is  driven  against  the  fluid  of  the  vestibule 
with  such  suddenness  and  violence  that  the  entire  contents  of  the  laby- 
rinthine capsule  must  inevitably  suffer  as  a  result.  In  such  cases  the 
middle  ear  is  usually  more  or  less  damaged  and  the  drum  membrane 
may  be  ruptured,  particularly  if  it  has  already  been  weakened  by  previous 
disease.  Another,  though  infinitely  slower,  cause  of  injury  by  concussion 
occurs  in  the  presence  of  continuous  and  moderately  loud  noises.  From 
such  a  cause  arises  that  form  of  labyrinthine  disease  commonly  known 
as  boilermaker's  deafness,  although  the  same  affection  may  be  acquired 
elsewhere  than  in  boiler-shops,  as,  for  instance,  in  driving  railway 
locomotives. 

The  cause  of  many  diseases  of  the  perceptive  portion  of  the  ear  are 
due  to  an  extension  of  a  previously  existing  middle-ear  disease.  Thus, 
many  aural  suppurations  are  at  first  confined  entirely  to  the  tympanic 
cavity,  but  in  the  course  of  their  progress  finally  implicate  the  labyrinth- 
ine structures.  The  same  is  true  of  some  cases  of  the  non-suppurative 


DISEASES   OF   PERCEPTIVE    PORTION   OF   HEARING    APPARATUS     519 

variety  of  middle-ear  catarrh,  which  disease  may  for  a  long  time  be 
limited  to  the  conducting  portion  of  the  hearing  organ,  but  may  ultimately 
affect  the  perceptive  apparatus  because  of  the  injury  which  results  to 
the  foot-plate  of  the  stapes  from  the  deposit  of  fibrous  or  osseous  tissue 
upon  and  around  it.  In  all  instances  where  the  labyrinth  is  secondarily 
involved  as  a  result  of  previous  diseases  in  the  middle  ear.  the  accom- 
panying impairment  of  hearing  is  designated  a  mixed  deafness. 

Symptoms. — Since  the  internal  ear  is  endowed  with  the  function  of 
regulating  the  static  equilibrium  as  well  as  of  providing  the  means  of 
sound  perception,  it  follows  that  deafness  is  present  to  a  greater  or 
less  extent  in  every  case  of  labyrinthine  disease,  and  disturbance  of 
equilibrium  is  a  symptom  in  many.  When  produced  by  trivial  causes, 
as,  for  instance,  the  pressure  of  hardened  ear-wax  in  the  external  audi- 
tory meatus,  the  degree  of  deafness  may  be  slight  and  will  completely 
disappear  upon  the  removal  of  the  cause  and  the  consequent  restora- 
tion of  the  disturbed  intralabyrinthine  pressure.  On  the  contrary,  how- 
ever, the  impairment  of  the  function  may  be  complete  and  permanent, 
as  happens  when  there  is  a  total  abatement  of  function  of  the  auditory 
nerve  for  any  cause.  Between  these  two  extremes  every  degree  of 
impairment  of  function  exists.  As  a  rule  affections  of  the  inner  ear  are 
progressive,  and  although  the  amount  of  deafness  is  but  trivial  in  the 
beginning,  in  the  course  of  a  few  months  or  years  the  loss  of  function  is 
sufficient  to  interfere  with  hearing  the  speaking  voice  and  may  make  it 
impossible  to  hear  the  ordinary  voice.  Occasionally  the  progress  toward 
profound  deafness  is  for  a  time  arrested,  only  to  resume  at  some  subse- 
quent period  when  the  individual  may,  perhaps,  be  suffering  from  some 
general  and  exhaustive  bodily  ailment.  Some  degree  of  hearing  for 
loud  sounds  persists  so  long  as  the  disease  is  confined  exclusively  to  the 
labyrinth,  and  hence  complete  absence  of  the  perception  of  sound  in 
any  case  is  certain  evidence  of  the  existence  of  disease  of  the  trunk  of 
the  auditory  nerve  or  of  the  auditory  center  in  the  brain. 

Certain  perversions  of  hearing  sometimes  accompany  the  deafness. 
Thus,  several  forms  of  paracusis  have  been  noted,  chief  among  which 
may  be  mentioned  diplacusis,  paracusis  acris,  and  paracusis  loci.  The 
first  of  these  perversions  represent  a  state  of  auditory  perception  in  which 
the  diseased  ear  hears  a  given  sound  either  abnormally  high  or  abnor- 
mally low.  Hence  the  individual  is  capable  of  recognizing  two  sounds 
of  different  degrees  of  intensity  when  only  one  should  be  normally  heard. 
Paracusis__acris  is  a  term  applied  to  the  auditory  state  in  which  the 
individual  perceives  sounds  with  a  greater  acuity  than  normal.  In 
other  words,  there  is  an  acoustic  hyperesthesia  and  the  sounds  are  often 


520  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

productive  of  painful  auditory  sensations.  This  auditory  phenomenon 
is  usually  accompanied  by  an  oversensibility  of  other  special  sense 
organs,  and  hence,  the  vision,  smell,  and  taste  may  be  simultaneously 
acute.  These  perverted  sensibilities  are  sometimes  harbingers  of 
approaching  deafness  and  serious  cerebral  disorder.  In  the  case  of 
paracusis  loci  the  individual  is  no  longer  able  to  determine  in  any  degree 
the  direction  from  which  any  given  sound  emanates. 

Disturbances  of  equilibrium  form  one  of  the  most  prominent 
symptoms  of  many  cases  of  labyrinthine  disease.  It  is  a  well-known 
clinical  fact  that  any  condition  arising  in  the  hearing  apparatus,  which 
increases  the  pressure  of  the  intralabyrinthine  fluids,  will  produce 
a  greater  or  less  degree  of  giddiness  of  the  individual.  Causes  acting 
from  without  are  principally  those  which  act  upon  the  foot-plate  of  the 
stapes,  drive  it  inward,  and  perhaps  fix  it  in  an  abnormal  position  through 
the  deposit  of  connective  or  osseous  tissue  in  this  locality.  Hence 
vertigo  is  a  common  symptom  of  otosclerosis,  adhesive  middle-ear 
catarrh,  and,  less  frequently,  of  chronic  suppurative  otitis  media.  It  may 
even  result  from  such  simple  ailments  as  closure  of  the  Eustachian  tube 
in  tubotympanic  catarrh  or  from  the  pressure  of  hardened  wax  against 
the  tympanic  membrane.  In  all  of  these  instances  the  vertigo  is  sec- 
ondary to  influences  transmitted  from  without  through  the  medium  of 
the  conducting  apparatus. 

Within  the  labyrinth  itself  vertigo  arises  from  increased  pressure  and 
irritation  due  to  a  variety  of  causes,  among  which  may  be  mentioned 
hyperemia,  primary  inflammation  with  effusion  of  serum,  hemorrhage 
into  any  portion  of  the  membranous  labyrinth,  and  infection,  either 
through  the  general  circulation  or  by  the  direct  introduction  into  it  of 
pathogenic  bacteria  from  the  middle  ear  or  cranial  cavity. 

Physiologists  are  practically  agreed  that  the  semicircular  canals,  and 
especially  their  ampullae,  have  to  do  with  the  maintenance  of  the  bodily 
equilibrium.  Hence  it  should  be  expected  that  disease  of  this  portion 
of  the  inner  ear  will  give  rise  to  the  most  severe  examples  of  aural  vertigo. 
Nausea  and  vomiting  at  times  accompany  the  dizziness,  which  in  its 
worst  form  may  be  sufficient  to  compel  the  individual  to  remain  quiet 
and  in  bed.  Tinnitus  aurium  is  seldom  absent  in  any  case  and  is  due 
to  the  same  causes  which  produce  the  vertigo.  Like  the  latter,  these 
causes  are  due  to  disturbance  of  the  normal  position  of  the  foot-plate  of 
the  stapes  in  the  oval  window,  or  to  increased  labyrinthine  pressure,  and 
irritation  of  the  auditory  nerve-endings  from  other  causes.  In  rare 
cases  the  head  noises  originate  external  to  the  ear,  as,  for  instance,  in  the 
adjacent  blood-vessels,  as  a  result  of  muscular  contraction,  or  they  may 


DISEASES    OF    PERCEPTIVE    PORTION   OF   HEARING   APPARATUS     52! 

be  due  to  hallucination.  These  latter  varieties  of  tinnitus  are  seldom  due 
to  labyrinthine  affection,  and  usually  occur  as  the  result  of  maladies 
entirely  distinct  from  the  ear,  as,  for  example,  in  mental  diseases  or  in 
affections  of  the  carotid  artery  or  jugular  vein. 

Diagnosis. — The  diagnosis  will  depend  much  upon  the  presence 
of  the  above  symptoms  and  upon  the  results  of  the  physical  examination. 
The  appearance  of  the  drum  membrane  and  the  state  of  patency  of  the 
Eustachian  tube  are  not  of  so  much  diagnostic  importance  in  diseases  of 
the  perceptive  portion  of  the  ear  as  are  the  physical  changes  in  these 
structures  in  disease  of  the  conducting  apparatus.  In  uncomplicated 
cases  of  labyrinthine  deafness,  particularly  when  the  deafness  has  been 
sudden  in  its  onset,  the  drum  membrane  will  more  than  likely  be  normal 
in  appearance  and  the  Eustachian  tube  will  most  probably  be  found 
normally  open.  A  sudden  deafness,  therefore,  in  a  case  in  which  the 
conducting  apparatus  is  found  upon  inspection  to  be  normal  is  highly 
indicative  of  disease  of  the  perceptive  portion  of  the  ear.  Progress  in 
the  deafness  is,  on  the  other  hand,  very  frequently  accompanied  by 
marked  changes  in  the  structure  of  both  the  Eustachian  tube  and  drum 
membrane,  and  these  changes  are  clearly  demonstrable  when  examined 
objectively.  In  this  class  of  aural  affection  the  labyrinthine  disease  is 
secondary  to  the  middle-ear  affection,  which  is  a  mixed  lesion  whose 
exact  nature  can  only  be  determined  by  a  combination  of  the  results  of 
all  the  methods  of  examination,  but  principally  by  functional  tests  by 
means  of  tuning-forks. 

The  functional  examination  should,  therefore,  in  no  case  be  neglected, 
especially  if  the  history  of  the  affection  points  strongly  toward  disease  of 
the  perceptive  portion  of  the  ear.  Tests  by  means  of  the  voice,  whisper, 
and  acoumeter  are  essential  to  a  determination  of  the  degree  of  deafness 
for  these  particular  sounds,  but  it  is  impossible  by  means  of  them  to 
ascertain  the  particular  part  of  the  auditory  apparatus  which  is  at  fault. 
For  this  latter  purpose  the  tuning-forks  (Fig.  115)  are  essential.  It  is 
a  clinical  fact  that  those  who  suffer  from  labyrinthine  deafness  hear  the 
low  notes  of  the  tuning-fork  relatively  well  by  air  conduction,  whereas 
they  hear  the  high  notes  relatively  badly.  The  reverse  of  this  is  true  in 
uncomplicated  middle-ear  affection.  Beginning  the  functional  exam- 
ination with  the  lowest  fork  of  the  Hartmann  set,  and  running  to  the 
highest,  if  it  should  be  found  that  C3  and  C4  are  not  heard  at  all,  whereas 
those  of  the  middle  scale,  Cl  and  C2,  are  heard  quite  well,  it  may  be  re- 
garded as  reasonably  certain  that  the  disease  is  labyrinthine.  If  in  any 
case  where  the  middle  tones  only  are  heard  by  air  conduction  it  is  found 
that  vibrating  C  or  Q  when  placed  on  the  center  line  of  the  cranium 


522  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

is  heard  better  in  the  least  affected  ear,  and  if  held  in  firm  contact  with 
the  mastoid  is  heard  a  shorter  time  than  when  held  in  close  proximity 
to  the  same  ear,  the  conclusion  that  the  disease  is  labyrinthine  will 
thereby  be  confirmed.  In  cases  of  mixed  deafness — i.  e.,  when  the 
deafness  is  due  to  disease  both  of  the  middle  ear  and  labyrinth — the 
results  of  the  tuning-fork  examination  are  not  always  definite.  Should 
bone  conduction  and  air  conduction  be  found  equal  in  an  ear  that  is 
profoundly  affected,  this  fact  would  be  indicative  of  a  mixed  deafness; 
particularly  would  such  a  conclusion  be  justified  if  the  physical  exam- 
ination revealed  a  retracted,  thickened  drum  membrane  and  a  disturbed 
patency  of  the  Eustachian  tube. 

When  a  bilateral  affection  of  nearly  equal  degree  exists,  the  per- 
ception of  the  vibrating  fork  when  placed  upon  the  median  line  of  the 
cranium  will  be  equal  in  each  ear,  whatever  the  cause  of  the  deafness 
may  be.  If,  however,  the  aural  defect  is  in  the  labyrinth,  the  perception 
for  the  fork  during  the  above  test  will  be  greatly  shorter  than  normal. 
Abnormally  short  duration  for  Schwabach's  test  and  a  positive  Rinne 
in  the  same  individual  are  strongly  indicative  of  perceptive  deafness. 

After  it  has  been  definitely  decided  that  the  defect  lies  in  the  per- 
ceptive portion  of  the  hearing  apparatus,  it  yet  remains  to  be  determined, 
if  possible,  whether  the  trouble  is  entirely  in  the  labyrinth  or  whether 
it  is  in  some  portion  of  the  trunk  of  the  auditory  nerve  or  center  of 
perception  in  the  brain.  Localization  in  this  respect  is  not  always  easy 
or  possible.  It  has  already  been  stated  that  cases  of  complete  deafness 
occurring  suddenly  may  often  be  regarded  as  having  an  origin  either  in 
the  nerve  trunk  or  auditory  center.  Should  the  latter  be  the  seat  of 
the  disease  other  physical  or  mental  phenomena  will  likely  be  present 
together  with  the  deafness. 

The  results  of  treatment  upon  the  hearing  have  also  some  diagnostic 
value,  for,  whereas  in  middle-ear  affections  inflation  of  the  middle  ear 
usually  improves  the  hearing  to  some  extent,  such  a  result  is  not  common 
in  purely  labyrinthine  deafness.  Should  benefit  result  from  treatment 
in  any  case  it  is  usually  slight  and  transitory.  Moreover,  the  outcome 
of  treatment  in  this  class  of  aural  affection  is  often  quite  the  opposite  to 
what  is  desired,  the  patient  growing  rapidly  worse  from  the  effect  of  air 
douches  and  catheter  inflation  of  the  tympanic  cavity.  Climatic  changes 
do  not,  as  a  rule,  produce  such  marked  effects  upon  the  hearing  in  purely 
labyrinthine  as  in  uncomplicated  middle-ear  affections.  Hence,  an 
uninterrupted  course  of  the  disease  under  all  conditions  of  climate  is 
somewhat  diagnostic  of  labyrinthine  affection. 

Since  nausea  and  vertigo  are  symptoms  of  several  other  diseases, 


DISEASES   OF    PERCEPTIVE    PORTION    OF   HEARING    APPARATUS     523 


the  particular  cause  of  their  occurrence  in  any  case  is  a  matter  of  no 
small  importance.  In  a  general  way  it  may  be  stated  that  these  symp- 
toms, when  accompanied  by  deafness  and  tinnitus  aurium  and  without 
other  assignable  reason  for  their  existence,  may  be  attributed  to  the 
aural  affection.  It  is  now  commonly  believed  that  many  cases  of  vertigo 
which  were  formerly  attributed  to  stomach  derangement  were,  in  fact, 
the  result  of  internal  ear  disease.  Affections  of  the  middle  lobe  of  the 
cerebellum  are  productive  of  nausea  and  vomiting  and  a  differential 
diagnosis  is  not  always  easy.  Both  cerebellar  and  labyrinthine  dis- 
turbances may  be  similarly  accompanied  by  these  symptoms  in  so  far 
as  the  severity  of  the  actual  disturbance  in  these  directions  go,  but  when 
due  to  an  affection  of  the  central  cerebellar  lobe  the  dizziness  and  nausea 
are  accompanied  by  others,  such  as  the  constant  tendency  of  the  patient 
to  fall  either  forward  or  backward,  nystagmus,  difficult  speech,  strabis- 
mus, paroxysms  of  pain  in  the  occiput,  and  other  more  distant  reflexes. 

DIFFERENTIAL  DIAGNOSIS  BETWEEN  MIDDLE-EAR  AND  LABYRINTHINE 

DISEASES 


Pain. 
Deafness. 


Tinnitus  aurium. 
Nausea  and  vertigo. 

History  of  case. 


Appearance  of  drum 
membrane. 


Condition  of  naso- 
pharynx and  Eustach- 
lan  tube. 


Climatic  changes. 


Effect  of  catheter 
inflation. 

Tuning-forks. 


Diseases  of  the  Conducting  Apparatus         Diseases  0}  the  Perceptive  Apparatus 

Present  only  in  the  acute  inflammatory    Usually  absent, 
affections. 

Present  in  greater  or  less  degree  in  all 
cases.  Usually  moderate  degree  of 
function  remains.  Deafness  never 
total.  Hearing  usually  better  in  a 
noise. 

Present  in  a  large  majority  of  cases. 
Absent  in  uncomplicated  cases. 


Present  in  greater  or  less  degree.  Often 
profound  and  total.  Hearing  usually 
worse  k  a  noise. 


Present  in  a  large  majority  of  cases. 

Present  in  many  cases.  Often  a  most 
prominent  feature  of  the  case. 

Often  follows  general  disease,  such  as 
cerebrospinal  meningitis,  typhoid 
fever,  mumps,  syphilis,  etc.  Also 
scarlatina,  measles,  and  la  grippe,  but 
in  these  latter  ailments  is  secondary 
to  tympanic  affection. 


Normal  in  uncomplicated  cases. 


Usually  history  of  injury  or  inflammation 
of  ear.  History  of  head  colds  and 
catarrhal  states  in  early  life,  with 
aural  discharge  in  many  cases  at 
some  time  during  course  of  diseases. 
Frequently  follows  scarlatina,  measles, 
la  grippe,  etc. 

Sunken,  perforated,  granulated,  or  thick- 
ened in  the  inflammatory  variety. 
Tendon-white,  thickened  in  whole  or 
part,  and  sometimes  contains  chalky 
deposits  in  non-suppurative  variety. 

Adenoids  and  other  nasal  obstruction  Adenoids,  nasopharyngeal  inflamma- 
frequently  present.  Xasopharyngeal  tions,  and  nasal  growths  absent,  or  if 
inflammation  common.  Eustachian  present  no  causative  relationship  to 
tube  often  narrowed.  aural  affection  can  be  traced.  Eus- 

tachian tube  normal. 

Conditions   of   weather    affect   hearing    Have  but  little  or  no  effect  upon  hearing 
greatly.     Hearins  better  during  bright        or  tinnitus, 
dry  state,  worse  during  damp,  cold 
days. 


Usually  some  improvement  in  hearing. 


Xo   improvement   in   hearing.     Patient 
often  made  worse. 


Low  tones  heard  relatively  bad  by  air     Low  notes  heard  relatively  well  by  air 


conduction.        Vibrating    tuning-fork 
C  heard  longer  by  bone  than  by  air 

conduction.      Rinne — r~.     Vibrating 

C   fork   on   median   line   of   cranium 
heard  best  in  worst  ear.   (Weber  test.) 


conduction.      Vibrating  fork  C  heard 

longer  by  air  than  by  bone  conduction. 

A  C 

_  _  Rinne  -f.     Vibrating  C  fork  on 

ij  C 

median  line  of  cranium  heard  best 

in  best  ear.     (Weber  test.) 


524  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

The  prognosis  in  disease  of  the  perceptive  portion  of  the  auditory 
apparatus  is,  in  the  majority  of  instances,  unfavorable.  The  nature  of 
the  pathology,  together  with  the  inaccessible  situation  of  this  class  of 
diseases,  is  largely  responsible  for  the  unsatisfactory  termination.  In 
some  instances,  as,  for  example,  in  mumps  and  syphilis,  the  perceptive 
mechanism  may  be  hopelessly  injured  from  the  first,  whereas  if  the 
trouble  is  due  only  to  the  irritation  of  the  auditory  nerve-endings  from  an 
increased  pressure  of  the  endolymph,  the  same  may  be  subsequently 
absorbed  and  the  perceptive  portion  of  the  organ  be  thereby,  at  least 
partially,  restored  to  the  normal.  When  secondary  to  an  injury  the 
damaged  labyrinth  may  also  be  partially  restored  and  the  same  may  be 
said  of  labyrinthine  syphilis,  provided  the  true  nature  of  the  disease  be 
diagnosed  early  and  an  appropriate  treatment  be  at  once  vigorously 
instituted. 

The  treatment  will  be  given  in  connection  with  the  description  of  the 
individual  diseases  comprising  this  class  of  aural  affections. 


CHAPTER  XLIII 

DISEASES   OF   THE  LABYRINTH   DUE   TO 
CIRCULATORY   DISTURBANCES 

L  ANEMIA  OF  THE  LABYRINTH 

Causation. — Anemia  of  the  labyrinth  stands  among  the  mildest  of 
the  affections  of  the  internal  ear.  It  is  often  a  mere  local  expression  of 
a  constitutional  impoverishment  of  the  blood  and,  as  such,  becomes  one 
of  the  symptoms  of  general  anemia.  The  cause  of  this  particular 
affection  is,  therefore,  the  same  as  that  which  is  responsible  for  the  con- 
stitutional ailment.  Thus,  a  severe  hemorrhage  occurring  in  any 
part  of  the  body  may  so  deplete  the  system  as  to  produce  immediate 
disturbance  of  hearing,  vertigo,  and  nausea.  On  the  other  hand,  the 
cause  may  have  come  on  more  slowly  and  as  the  result  of  a  prolonged 
and  exhaustive  illness,  of  malnutrition,  or  perhaps  of  rapid  childbearing. 
Certain  drugs,  when  administered  in  excessive  amounts  or  for  prolonged 
periods,  are  productive  of  cerebral  anemia  and,  with  it,  of  labyrinthine 
anemia.  Chief  among  these  drugs  may  be  mentioned  the  bromids  of 
sodium  and  potassium,  hydrobromic  acid,  and  ergot. 

Symptoms. — The  aural  symptoms  of  this  disorder  are  deafness, 
tinnitus,  and  vertigo.  The  degree  of  deafness  is  usually  slight  and 
partakes  more  of  the  nature  of  an  exhausted  perception  for  sound  rather 
than  of  an  actual  defect  of  hearing.  The  perceptive  mechanism  suffers 
from  a  similar  lack  of  tone  to  that  which  characterizes  the  mental  and 
physical  activities  of  the  individual,  all  of  which  are  more  or  less  impaired. 
While  the  patient  seems  able  to  hear  almost  normally,  he  is  nevertheless 
conscious  that  he  must  constantly  put  forth  an  effort  to  do  so  and,  as 
a  result,  it  is  found  tiresome  to  carry  on  a  prolonged  conversation.  The 
tinnitus  aurium  which  accompanies  anemia  of  the  labyrinth  is  to  some 
extent  at  least  produced  in  the  venous  circulation  of  the  large  cervical 
veins,  and  hence  it  partakes  somewhat  of  the  character  of  the  bruit  often 
heard  by  the  examiner  during  an  examination  of  these  vessels  in  anemic 
subjects.  The  noises  heard  by  the  patient  are,  therefore,  usually 
described  as  more  or  less  continuous  and  low  pitched  in  character.  The 
vertigo  is  rather  the  result  than  otherwise  of  the  predisposition  of  the 
patient  toward  this  affection,  which  is,  of  course,  greatly  increased  by 
the  general  and  labyrinthine  anemia.  Hence  when  the  individual  so 

525 


526  THE  PRINCIPLES  AND  PRACTICE  OF  OTOLOGY 

affected  is  quiet,  both  in  mind  and  body,  there  may  be  absolutely  no 
dizziness  present;  whereas  a  trivial  mental  or  bodily  excitement  may 
give  rise  to  very  distressing  disturbances  of  equilibrium,  the  patient 
perhaps  undergoing  a  severe  faint. 

Diagnosis. — The  diagnosis  of  labyrinthine  anemia  will  be  justified 
by  the  history  of  a  recent  hemorrhage  or  serious  illness,  by  the  pallor  of 
the  skin  and  mucous  membranes,  and  by  a  microscopic  blood-count. 
In  addition  a  physical  and  functional  examination  of  the  ear  are  essential. 
The  appearance  and  position  of  the  membrana  tympani  will  usually  be 
normal  and  the  condition  of  the  Eustachian  tube  will  be  that  of  its  usual 
patency.  By  means  of  the  functional  tests  it  will  be  ascertained  that 
perception  for  spoken  words  is  slow,  and  that  the  hearing  for  the  higher 
notes  is  considerably  reduced.  The  C  tuning-fork  is  heard  by  bone 
conduction  for  a  much  shorter  time  than  normal. 

Prognosis. — The  prognosis  is  good  in  cases  which  have  resulted 
from  general  hemorrhage,  and  from  exhaustive  diseases  which  of  them- 
selves, or  through  judicious  treatment,  are  capable  of  restoration  to  the 
normal.  When  caused  by  pernicious  anemia  or  by  malignant  or  incur- 
able disease  the  aural  complication  will  likely  grow  worse  instead  of 
better,  and  in  some  cases  the  hearing  will  be  lost  because  of  the  accom- 
panying degeneration  of  the  auditory  nerve. 

Treatment. — An  effort  should  be  made  at  the  earliest  possible 
moment  to  correct  the  cause  of  the  general  anemia.  Hence  if  loss  of 
blood  continues,  as,  for  example,  in  bleeding  piles,  metrorrhagia,  or 
epistaxis,  the  cause  of  such  waste  should  at  once  be  remedied.  Impov- 
erishment of  blood  as  a  consequence  of  digestive  disorder  must  receive 
proper  medicinal  and  dietary  attention.  Regulation  of  all  the  habits  of 
the  individual,  including  care  as  to  the  amount  and  quality  of  the  food 
and  the  proper  amount  of  exercise  and  rest,  is  all  that  is  required  to 
bring  about  a  cure  in  many  cases.  The  improvement  may  often  be 
hastened  by  the  administration  of  drugs.  The  combination  of  remedies 
contained  in  the  elixir  of  calisaya,  iron,  and  strychnin  is  valuable  in  this 
respect,  since  the  calisaya  is  an  excellent  tonic  and  stomachic,  the  iron 
furnishes  a  needed  element  in  blood  making,  and  the  strychnin  acts  as 
a  stimulant  to  the  sluggish  endings  of  the  auditory  nerve.  Local  treat- 
ment of  the  ear  is  usually  not  indicated. 

n.   HYPEREMIA   OF   THE   LABYRINTH 

This  affection  may  be  of  an  active  or  passive  nature  and  may  be 
either  primary  or  secondary.  Primary  hyperemia  of  the  labyrinth  is 
a  rather  rare  affection,  whereas  that  which  is  secondary  to  a  similar 


DISEASES   OF   LABYRINTH    DUE   TO   CIRCULATORY   DISTURBANCES      527 

circulatory  disturbance  of  the  meninges  or  to  a  congestion  or  inflam- 
mation of  the  middle  ear  is  of  more  common  occurrence. 

Causation. — The  primary  variety  usually  results  from  a  general 
condition  of  plethora  of  the  individual  or  from  a  stasis  due  to  some 
mechanical  interference  with  the  return  venous  circulation.  In  the 
first  instance  any  severe  bodily  exertion  may  give  rise  to  the  affection 
and  overstimulation  of  the  heart  as  a  result  of  the  use  of  alcoholics  may 
bring  about  the  same  end.  Ascent  to  a  great  height,  as  in  a  balloon  or 
upon  a  mountain,  brings  about  a  labyrinthine  hyperemia  in  conjunction 
with  the  general  increased  flow  of  blood  to  the  surface  of  the  body. 
Among  other  primary  causes  may  be  mentioned  overeating,  gout, 
rheumatism,  and  the  ingestion  of  certain  drugs.  Ether,  quinin,  or 
salicin  and  its  compounds,  when  taken  in  large  and  frequently  repeated 
doses,  will  cause  an  increased  flow  of  blood  to  the  labyrinth.  A  more 
moderate  dosage  may  produce  only  a  physiologic  hyperemia,  whereas 
if  taken  in  large  quantity,  serous  effusion  into  the  membranous  capsule 
may  result  or  a  hemorrhage  into  the  labyrinth  may  follow.1  Passive 
hyperemia  results  from  any  cause  which  retards  the  venous  return  of 
the  labyrinthine  circulation.  Hence  the  position  of  the  body,  as  when 
the  head  is  hanging  down;  the  thoracic  obstruction  which  occurs  during 
prolonged  fits  of  sneezing,  coughing,  or  from  holding  the  breath  while 
straining,  swimming,  or  diving,  are  all  factors  in  the  production  of  this 
particular  aural  disturbance. 

Secondary  labyrinthine  hyperemia  occurs  as  the  result  of  an  extension 
through  the  channel  of  the  internal  auditory  meatus  of  a  similar  hyper- 
emia of  the  meninges;  or  the  disease  may  enter  the  labyrinth  from 
without,  the  affection  having  first  traversed  the  Eustachian  tube  and 
middle  ear.  Thus,  on  the  one  hand,  the  labyrinthine  disease  in  question 
may  be  only  a  symptom  of  meningitis,  encephalitis,  etc.,  while  on  the 
other,  it  may  be  a  symptom  of  measles,  scarlet  fever,  la  grippe,  or  other 
infectious  ailment  which  has  a  special  tendency  to  involve  the  middle  ear 
primarily  and  the  inner  ear  secondarily. 

Symptoms. — A  feeling  of  fulness  in  the  head  and  moderate  impair- 
ment of  hearing  may  be  the  only  symptoms  of  the  mild  and  transitory 
case;  such,  for  instance,  as  that  which  results  from  mountain  climbing, 
sudden,  violent  exertion,  or  from  hanging  the  head  downward.  In  cases 
where  the  congestion  is  prolonged  or  is  the  result  of  more  serious  causes 
the  tinnitus  may  be  violent  and  may  be  accompanied  by  vertigo,  disturbed 

1  Kirchner,  of  Wurzburg,  administered  large  doses  of  quinin  to  rabbits,  which  were 
subsequently  killed  and  the  effect  upon  the  ears  noted.  It  was  found  that  congestion 
and  hemorrhage  had  taken  place,  both  into  the  labyrinth  and  middle  ear. 


528  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

equilibrium,  and  nausea.  A  plethoric  state  of  the  individual  is  usually 
indicated  by  the  tendency  toward  inflammatory  affections  and  also  by 
the  hyperemic  state  of  the  capillaries  of  the  skin  of  the  face,  particularly 
of  the  nose.  In  primary  congestion  the  hearing  is  only  moderately 
affected,  whereas  when  it  occurs  secondarily  to  severe  inflammatory 
diseases  of  the  brain  or  middle  ear  the  loss  of  function  may  be  very 
considerable  or  even  complete. 

Diagnosis. — In  the  diagnosis  of  this  affection  the  history  of  the 
mode  of  onset  and  progress  of  the  disease,  as  well  as  the  results  of  the 
physical  and  functional  examination  of  the  ear,  must  be  taken  into 
account.  When  the  labyrinthine  hyperemia  is  primary  and  due  to 
general  plethora  the  drum  membrane  will  usually  show  evidences  of 
increased  vascularity,  just  as  will  the  integument  of  the  face  and  nose. 
In  the  secondary  variety,  particularly  when  the  labyrinthine  disorder 
follows  some  very  active  inflammatory  state  of  the  drum  cavity,  the 
appearance  of  the  drum  membrane  will  be  governed  by  the  amount  and 
character  of  the  tissue  changes  that  have  taken  place  in  the  middle  ear, 
and  these  will  in  no  way  be  indicative  of  the  presence  of  an  inner  ear 
complication.  Secondary  labyrinthine  affections  cannot,  therefore, 
be  determined  by  means  of  the  physical  appearance  of  the  fundus  of 
the  ear. 

The  severe  examples  of  labyrinthine  hyperemia  may  simulate 
Meniere's  disease.  Indeed,  it  is  probable  that  such  a  hyperemia  is  the 
immediate  precursor  of  a  labyrinthine  apoplexy.  Hence  it  may  some- 
times be  difficult  to  distinguish  the  one  from  the  other,  except  after 
a  lapse  of  time;  for  whereas  if  the  case  is  one  of  hyperemia  only,  sub- 
sidence of  the  congestion  with  recovery  will  in  time  probably  occur, 
while  if  an  actual  hemorrhage  has  taken  place  into  the  labyrinth  such 
a  marked  result  will  scarcely  be  attained. 

Functional  tests  will  show  that  low  notes  will  usually  be  heard  better 
than  high  ones  and  that  bone  conduction  is  better  than  air  conduction. 

Prognosis. — Should  the  affection  be  recent  and  due  to  such  causes 
as  overindulgence  in  food,  stimulants,  or  exercise,  improvement  or  cure 
may  be  anticipated.  When  occurring  as  a  result  of  a  retarded  venous 
circulation  due  to  the  pressure  of  tumors,  when  the  result  of  chronic 
alcoholism,  or  when  secondary  to  serious  inflammatory  lesions  of  the 
meninges  or  middle  ear,  the  outlook  is  not  so  hopeful  and  a  return  to 
normal  is  not  to  be  anticipated.  Should  hemorrhage  into  the  labyrinth 
have  taken  place,  a  most  unfavorable  prognosis  should  be  given  (see 

P-  53i)- 

Treatment. — The  management  of  this  affection  should  be  deter- 


DISEASES   OF   LABYRINTH   DUE   TO    CIRCULATORY   DISTURBANCES     529 

mined  by  its  cause  in  any  particular  case.  Hence,  if  the  result  of  errors 
of  diet,  the  excessive  use  of  alcoholics,  or  of  violent  and  excessive  bodily 
exertion,  the  individual  must  be  instructed  to  correct  the  fault  by  re- 
turning to  habits  more  moderate  and  normal.  Evidences  of  active 
labyrinthine  hyperemia  in  plethoric  subjects  require  depletion  by 
purgation,  diaphoresis,  or  the  abstraction  of  blood.  In  instances  where 
the  symptoms  are  severe  and  there  is  great  danger  of  hemorrhage  into 
the  labyrinth,  2  or  3  ounces  of  blood  should  at  once  be  abstracted  from 
the  mastoid  region  by  means  of  the  artificial  leech  (Fig.  75).  If 
cerebral  apoplexy  seems  threatening,  a  greater  quantity  of  blood  may  be 
more  advantageously  withdrawn  from  the  arm.  In  milder  cases  depend- 
ence may  be  placed  upon  purgation  and  sweating.  Salines  should  be 
given  in  doses  sufficiently  large  to  secure  several  watery  stools.  Mean- 
while the  patient  is  advised  to  remain  quiet  in  bed  with  the  head  elevated. 
If  satisfactory  improvement  does  not  follow  the  administration  of  the 
foregoing  measures,  pilocarpin  should  be  employed,  either  in  addition 
or  as  a  substitute.  This  drug  is  believed  to  have  an  especial  value  when 
used  in  cases  where  there  has  been,  in  addition  to  the  labyrinthine 
hyperemia,  a  serous  effusion  into  the  membranous  capsule.  lodid  of 
potassium  is  also  a  remedy  of  value  in  case  labyrinthine  effusion  has 
already  occurred,  but  is  of  greatest  sendee  when  employed  in  those  that 
have  not  yielded  readily  to  other  measures  and,  therefore,  in  cases  that 
are  subacute  or  chronic. 

UL    LABYRINTHINE   HEMORRHAGE,   MENIERE'S   DISEASE 

Causation. — Extravasation  of  blood  into  the  labyrinth  often  follows 
an  active  hyperemia,  particularly  when  the  latter  occurs  in  persons  with 
atheromatous  blood-vessels.  The  hemorrhage  may  follow  a  rapidly 
developed  hyperemia  of  the  labyrinth,  such,  for  instance,  as  accom- 
panies scarlet  fever,  measles,  mumps,  variola,  and  typhoid  fever.  Post- 
mortem examination  of  the  inner  ears  of  those  who  have  died  from 
suffocation  usually  reveals  ecchymotic  areas  upon  the  membrane  cover- 
ing the  lamina  spiralis,  the  membrane  of  the  vestibule,  and  of  the 
ampullae  The  low  state  of  vitality  which  accompanies  pernicious 
anemia  is  conducive  to  the  occurrence  of  small  labyrinthine  ecchy- 
mosis.  Those  employed  in  architectural  construction  requiring  several 
hours  each  day  to  be  spent  in  a  caisson  have  been  found  to  suffer  from 
labyrinthine  hemorrhages.  The  chief  danger  to  the  labyrinth  from  this 
latter  cause  seems  to  occur  from  the  too  rapid  release  of  the  pressure 
within  the  vessel  in  which  the  workmen  are  confined. 

Labyrinthine  hemorrhage  may  also  be  of  traumatic  origin.     Severe 

34 


530  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

injuries  to  the  skull,  resulting  in  fracture  of  the  petrous  portion  of  the 
temporal  bone,  results  in  rupture  of  the  blood-vessels  of  the  parts,  and 
the  bleeding,  therefore,  occurs  from  direct  injury.  A  hemorrhage  in 
this  part  may,  however,  take  place  as  a  result  of  concussion  of  the  skull, 
in  which  instance  the  cause  acts  more  or  less  indirectly.  Caries  and 
necrosis  of  the  portion  of  the  temporal  bone  in  which  the  inner  ear  is 
situated  is  also  responsible  for  some  cases  of  ecchymosis  of  part  of  the 
membranous  capsule  or  of  free  bleeding  into  one  or  more  of  the  laby- 
rinthine spaces.  Operative  measures  in  the  middle  ear,  undertaken 
with  a  view  of  removing  or  mobilizing  the  stapes,  may,  if  undue  force  or 
rudeness  is  exerted,  result  in  a  hemorrhage  into  the  vestibule. 

Symptoms.— ^The  symptoms  of  this  affection,  which  is  sometimes 
called  apoplectiform  deafness,  constitute  a  complex  very  commonly 
known  as  Meniere's  disease.  The  patient  is  often  suddenly  seized  with 
aural  vertigo  and  vomiting  of  such  severity  that  he  falls  as  from  a  cerebral 
apoplexy,  and  is  subsequently  unable  to  sit  or  stand  erect  without 
support,  chiefly  because  of  the  increased  vertigo  and  nausea.  Deafness, 
which  is  more  or  less  complete,  constantly  accompanies  the  above- 
marked  features  of  the  disease.  Complete  unconsciousness  apparently 
occurs  in  the  worst  cases,  although  it  is  characteristic  of  this  disease  that 
the  patient  is  all  the  time  fully  aware  of  his  surroundings  and  can  sub- 
sequently narrate  all  that  has  transpired  during  the  height  of  the  attack. 
Premonitions  of  labyrinthine  hemorrhage  occur  in  cases  of  chronic 
congestion  of  the  middle  ear.  These  take  the  form  of  a  heaviness  about 
the  head,  some  unsteadiness  of  gait,  and  an  increase  of  the  previous 
tinnitus  aurium.  After  the  occurrence  of  the  apoplexy  the  head  noises 
are  very  much  intensified  and  are  often  quite  intolerable.  Genuine 
cases  of  Meniere's  disease  occur  most  frequently  in  persons  of  middle  life 
and  of  plethoric  habit,  and  in  whom  the  above  symptoms  take  place  with 
a  suddenness  comparable  with  that  of  an  individual  affected  by  a  severe 
and  genuine  cerebral  apoplexy.  During  and  immediately  subsequent 
to  the  labyrinthine  hemorrhage  the  face  appears  pale  and  anxious  and 
is  covered  with  a  profuse  perspiration. 

The  objective  symptoms  are  either  negative  or  similar  to  those 
accompanying  labyrinthine  hyperemia.  If  the  middle  ear  is  implicated, 
ecchymotic  areas  may  show  in  the  drum  membrane.  A  careful  func- 
tional examination  shows  that  both  air  and  bone  conduction  are  greatly 
lessened  or  even  absent.  Perception  for  the  C  fork  may  be  equal  for 
both  air  and  bone  conduction.  It  sometimes  happens  that  there  is 
complete  loss  of  hearing  for  all  tones  with  the  exception  of  that  for  a 
small  portion  of  the  scale;  or  gaps  in  the  scale  may  be  found  to  exist; 


DISEASES   OF   LABYRINTH    DUE   TO    CIRCULATORY   DISTURBANCES     53! 

that  is,  in  testing  all  parts  of  the  scale  there  may  be  complete  deafness 
for  certain  tones,  then  an  "island"  of  perception  is  discovered,  which, 
being  succeeded  by  an  area  of  deafness,  is  in  turn  followed  by  one 
capable  of  perceiving  certain  sounds.  These  phenomena  of  function 
are  explained  by  the  probable  fact  that  the  hemorrhage  has  destroyed 
certain  portions  of  the  basilar  membrane  in  portions  of  the  cochlea, 
leaving  undisturbed  only  partially  destroyed  areas  between. 

The  above  symptoms  usually  continue,  sometimes  to  a  lessened,  but 
often  in  a  progressively  aggravated,  degree.  Should  the  immediate 
apoplectiform  symptoms  subside  sufficiently  to  permit  the  patient  to  be 
up  and  around,  he  usually  walks  with  an  unsteady  gait,  which  is  made 
better  or  worse  by  every  trivial  error  in  diet  or  exercise.  The  hearing 
power  often  grows  progressively  worse  instead  of  better  and  ultimately 
ends  in  total  deafness.  The  severity  of  the  tinnitus  bears  a  close  rela- 
tionship to  the  degree  of  deafness,  but  sometimes  disappears  altogether 
when  the  hearing  is  entirely  lost. 

Diagnosis. — The  diagnosis  should  usually  be  made  if  a  majority  of 
the  above  symptoms  are  present  in  a  marked  degree.  Meniere's  disease 
may  be  mistaken  for  cerebral  apoplexy,  but  in  the  latter  affection  symp- 
toms of  paralysis  of  the  tongue,  face,  or  extremities  usually  quickly  shows 
the  cerebral  nature  of  the  case,  whereas  if  the  inner  ear  only  is  involved 
these  paralyses  are  absent  and  the  other  symptoms,  together  with  the 
functional  examination,  point  strongly  to  the  ear  as  the  seat  of  the  lesion. 

Prognosis. — It  has  already  been  pointed  out  in  what  has  been  said 
concerning  the  causation  and  diagnosis  that  the  prognosis  of  this  affec- 
tion is  usually  unfavorable.  In  mild  cases  of  recent  occurrence  partial 
recovery  takes  place.  The  lost  hearing  can  seldom  be  restored  and 
relapses  of  the  vertigo  and  tinnitus  are  the  rule. 

Treatment. — The  same  measures  that  were  recommended  for  the 
treatment  of  labyrinthine  hyperemia  are  indicated  in  case  of  hemorrhage 
into  this  portion  of  the  ear.  When  the  patient  is  seen  during  the  attack 
and  is  plethoric,  general  blood-letting  should  be  immediately  practised. 
In  those  only  moderately  full  blooded,  natural  or  artificial  leeches  may 
be  sufficient.  The  patient  should  be  put  to  bed  with  the  head  elevated. 
A  hot  mustard  foot-bath  may  be  administered  simultaneously  with  the 
employment  of  other  measures  intended  to  relieve  the  cerebral  con- 
gestion. Saline  purgatives  should  be  given  for  the  double  purpose  of 
clearing  the  digestive  tract  and  of  acting  as  a  derivative. 

Following  the  subsidence  of  the  active  symptoms,  either  naturally 
or  as  a  result  of  treatment,  the  diet  should  be  carefully  regulated;  severe 
exercise,  either  mental  or  bodily,  should  be  prohibited,  and  the  state  of 


532  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

the  bowels,  especially  constipation,  should  be  overcome  by  the  use  of 
cascara  sagrada  and  salines.  Two  drugs  are  believed  to  exert  an 
influence  in  hastening  the  absorption  of  effusions  of  blood  or  serum  into 
the  labyrinth.  These  are  potassium  iodid  and  pilocarpin,  the  methods 
of  administering  which,  as  well  as  the  resulting  action  of  the  same,  has 
been  described  in  another  chapter  (see  p.  529). 

IV.    EMBOLISM    OR    THROMBOSIS 

These  affections  of  the  labyrinth  are,  no  doubt,  among  the  rarest  of 
internal  ear  disorders.  It  is  possible,  however,  that,  owing  to  the  diffi- 
culty with  which  such  occurrences  are  recognized,  the  occlusion  of  the 
labyrinthine  vessels  by  a  blood-clot  is  not  often  recognized,  a  fact 
which  would  account  for  the  supposed  rarity  of  the  affection. 

The  cause  lies  either  in  the  presence  of  a  thrombus  in  some  distant 
part,  from  which  an  embolus,  either  infected  or  sterile,  is  transported  to 
the  labyrinth;  or  the  thrombosis  of  the  labyrinthine  veins  may  occur  as  a 
result  of  the  direct  extension  of  a  thrombus  in  some  of  the  venous  sinuses 
in  the  immediate  vicinity  of  the  inner  ear  (see  Fig.  274).  The  thrombus 
may  also  extend  directly  to  the  labyrinth  from  the  veins  of  the  middle 
ear  during  the  severe  suppurative  processes  which  take  place  in  that 
cavity  during  the  course  of  the  exanthemata. 

Symptoms. — Since  the  occlusion  of  the  labyrinthine  vessel,  especially 
by  an  embolus,  takes  place  suddenly,  it  should  be  expected  that  the 
resulting  aural  symptoms  would  be  correspondingly  sudden.  The 
hearing  power  may  or  may  not  be  affected,  this  depending  much  upon 
whether  or  not  the  vessels  supplying  the  cochlea  are  occluded  or  whether 
the  obstruction  is  in  one  of  the  venules  of  the  vestibule  or  ampulla:  of  the 
semicircular  canals.  If  in  the  former,  some  degree  of  deafness  will 
undoubtedly  follow,  whereas  if  the  latter  parts  are  affected,  tinnitus  and 
vertigo  will  likely  be  the  most  prominent  symptoms. 

Objective  symptoms  are  absent  unless  the  affection  is  secondary  to 
some  variety  of  otitis  media,  in  which  instance  the  appearances  of  the 
fundus  of  the  ear  would  correspond  to  that  produced  by  the  particular 
primary  disease.  The  presence  of  tubal  or  nasopharyngeal  affection  is 
not  found  except  as  contributing  factors  in  the  production  of  any  accom- 
panying tympanic  inflammation  or  suppuration. 

Diagnosis. — The  diagnosis  is  not  easy,  for  the  reason  that  obstruc- 
tion to  the  labyrinthine  circulation  from  the  above  causes  gives  rise  to 
symptoms  very  closely  resembling  several  other  diseases  of  the  internal 
ear,  especially  hyperemia,  hemorrhage,  and  syphilis,  in  all  of  which 
deafness,  nausea,  vertigo,  and  impaired  bone  conduction  constitute 


DISEASES   OF   LABYRINTH   DUE   TO    CIRCULATORY   DISTURBANCES     533 

prominent  symptoms.  In  any  case  in  which  vertigo  and  tinnitus  come 
on  suddenly  in  an  otherwise  healthy  individual  and  these  symptoms  are 
not  accompanied  by  impairment  of  hearing,  it  may  be  assumed,  provided 
no  middle-ear  disease  is  present  and  bone  conduction  is  found  greatly 
diminished,  that  an  embolus  or  thrombosis  of  the  vestibular  veins  has 
occurred.  Should  more  or  less  deafness  accompany  the  tinnitus  and 
vertigo,  it  is  more  probable  that  the  cochlear  veins  are  involved.  It 
must  be  admitted,  however,  that  a  positive  diagnosis  can  seldom  be  made. 
Treatment. — Local  treatment  is  not  advisable.  If  any  cause  for 
the  affection  can  be  discovered,  this  should  be  eliminated,  if  possible, 
with  a  view  to  preventing  a  recurrence  of  the  trouble.  For  the  relief  of 
the  tinnitus  aurium  and  vertigo,  pilocarpin  and  potassium  iodid  may  be 
given  internally,  as  described  on  p.  529.  The  administration  of  bromids 
or  of  dilute  hydrobromic  acid  are  most  effectual  for  the  relief  of  the  head 
noises. 


CHAPTER  XLIV 
INFLAMMATION    OF   THE   LABYRINTH 

I.    PRIMARY   OTITIS    INTERNA 

BECAUSE  of  its  depth  and  protected  situation,  inflammation  of  the 
labyrinth,  which  begins  as  a  primary  disease,  is  among  the  rarest  of 
aural  affections.  Voltolini  and  Politzer  have  mentioned  instances  in 
which  labyrinthine  inflammation  occurred  entirely  independent  of  otitis 
media,  meningitis,  or  other  disease  of  an  inflammatory  nature.  The 
primary  affection  occurs  in  children  who  are  otherwise  healthy  up  to  the 
moment  of  seizure  with  deafness,  fever,  vomiting,  delirium,  and  some- 
times unconsciousness  and  convulsions.  All  these  symptoms  subside 
within  a  few  days,  with  the  exception  of  the  vertigo  and  deafness,  both 
of  which  persist  for  some  weeks  and  may  last  for  an  indefinite  period. 
Labyrinthine  inflammation  may  be  mistaken  for  meningitis,  which  it 
greatly  simulates,  and  time  alone  furnishes  the  best  data  for  a  differ- 
ential diagnosis;  for  whereas  the  disease  in  question  may  run,  its  course 
in  a  few  days,  the  symptoms  of  meningitis  usually  persist  for  many  weeks, 
and  the  resulting  effects  of  the  latter  disease  upon  the  auditory  apparatus 
are  more  marked  and  lasting. 

H.   SECONDARY   OTITIS   INTERNA    (ACUTE) 

•Causation. — While  an  acute  inflammatory  involvement  of  the 
labyrinth  occurs  usually  as  one  of  the  results  of  scarlet  fever,  measles, 
diphtheria,  typhus  or  typhoid  fever,  it  has  also  been  known  to  compli- 
cate an  acute  otitis  media  which  follows  traumatic  injury  to  the  drum 
membrane  and  middle  ear,  to  follow  the  accidental  entrance  of  fluids 
into  the  Eustachian  tube,  and  to  occur  subsequent  to  the  infection  of 
the  tympanum  from  pathogenic  bacteria  during  severe  attacks  of  tonsil- 
litis or  nasopharyngitis.  Age  is  a  predisposing  cause  of  the  extension 
of  the  inflammation  from  the  middle  ear  to  the  labyrinth.  Young 
children  are  more  frequently  affected  than  adults,  for  the  reason  that 
the  osseous  partition  between  the  several  portions  of  the  labyrinth  and 
middle  ear  is  thinner  in  early  than  in  later  life,  and  for  the  further 
reason  that  nasopharyngeal  obstruction  is  common  at  this  age;  and, 
moreover,  the  chief  cause  of  acute  secondary  labyrinthine  inflamma- 

534 


INFLAMMATION   OF   THE    LABYRINTH  535 

tion — namely,  the  acute  infectious  diseases — occur  chiefly  during  child- 
hood. 

In  the  mildest  cases  of  acute  otitis  media  purulenta  the  internal  ear 
is  probably  but  seldom  involved  in  a  secondary  inflammation;  in  the 
more  severe  forms  of  tympanic  suppuration  otitis  interna  more  frequently 
complicates  the  primary  aural  affection,  whereas  in  the  violently  de- 
structive forms  of  the  otitis  media,  especially  those  due  to  scarlatina,  the 
labyrinth  is  sometimes  exposed  by  caries  or  necrosis  of  the  inner  tympanic 
wall,  infection  of  the  labyrinthine  fluids  takes  place,  and  a  suppurative 
otitis  interna  results.  This  latter  affection,  sometimes  designated 
panotitis,  deserves  a  separate  discussion. 

Symptoms. — The  symptoms  are  those  which  accompany  affections 
of  the  labyrinth  in  general — namely,  sudden  deafness,  tinnitus  aurium, 
vertigo,  and  vomiting.  The  onset  of  the  extension  of  the  inflammation 
to  the  cavities  of  the  inner  ear  is  very  frequently  not  recognized  at  the 
time,  either  for  the  reason  that  the  child  is  too  young  to  enable  the 
examiner  to  obtain  accurate  information  concerning  the  nature  of  the 
disease  or  else  the  accompanying  symptoms  of  the  scarlet  fever  or  other 
causative  general  ailment  which  is  present  are  so  severe  as  to  overshadow 
the  aural  complication,  or  even  to  preclude  an  examination  for  the 
purpose  of  determining  its  existence.  In  cases  of  longer  standing  there 
is  a  history  of  present  or  remote  middle-ear  suppuration,  and  back  of 
all  this  is  the  history  of  the  child  having  had  some  general  infective 
disease,  as,  for  example,  scarlet  fever,  typhoid,  or  typhus  fever. 

Diagnosis. — In  addition  to  the  history  of  the  case,  which  includes 
a  recital  of  the  above  symptoms,  the  physical  examination  will  show  more 
or  less  damage  to  the  drum  membrane  and  middle  ear.  Indeed,  any  one 
or  more  of  the  many  pathologic  conditions  of  the  membrana  tympani 
and  tympanic  cavity  which  have  been  described  in  the  chapter  devoted 
to  Acute  Otitis  Media  Purulenta  may  be  found  present  in  this  disease. 
The  functional  examination  is  here,  as  in  all  affections  of  the  labyrinth, 
an  absolute  essential  to  correct  diagnosis.  If,  in  a  suspected  case  of 
secondary  otitis  interna,  it  is  found  that  the  tuning-forks  C2,  C3,  and  C4 
are  heard  badly  or  are  not  heard  at  all  by  air  conduction;  if  it  is  found 
that  Rinne  is  positive,  and  that  the  C  fork  by  Weber's  test  is  heard  best 
in  the  good  ear,  it  may  be  safely  stated  that  the  perceptive  portion  of  the 
ear  is  involved.  It  must  be  remembered  in  all  cases  of  secondary 
labyrinthinitis  that  a  mixed  deafness  is  present ;  that  is,  a  deafness  which 
is  due  both  to  a  hindrance  of  the  passage  of  the  sound-waves  through 
the  conducting  apparatus  and  to  an  impairment  of  the  perception  of  the 
same. 


536  THE   PRINCIPLES   AND   PRACTICE    OF   OTOLOGY 

It  should,  therefore,  be  expected  that  the  functional  tests  will  give 
results  which  differ  from  those  found  when  the  disease  is  either  purely 
labyrinthine  or  purely  tympanic.  Thus,  the  tests  may  indicate  a  normal 
relationship  as  to  the  duration  of  perception  for  a  given  sound  by  both 
air  and  bone  conduction,  but  the  actual  duration  of  the  hearing  for  each 
test  will  be  greatly  reduced.  In  very  young  children,  and  even  in  older 
ones  who  are  yet  too  young  to  give  intelligent  information  concerning 
the  functional  tests,  an  exact  diagnosis  is  impossible;  but,  during  the 
progress  of  an  acute  exanthema,  the  labyrinthine  complication  may 
always  be  strongly  suspected  if,  in  addition  to  a  middle-ear  suppuration, 
there  is  suddenly  added  profound  deafness,  annoying  tinnitus,  vertigo, 
and  vomiting. 

Prognosis. — The  prognosis  as  to  recovery  of  the  hearing  is  not  good, 
yet  undoubtedly  there  are  many  cases  in  which  recovery  takes  place  and 
the  function  is  restored  to  a  useful  degree.  The  tinnitus  aurium  usually 
subsides  as  the  hearing  improves  and  it  may  also  disappear  entirely  in 
case  the  function  is  entirely  destroyed.  Likewise  the  vertigo  and  nausea, 
when  present  at  first,  may  gradually  improve  and  finally  subside  alto- 
gether, even  in  cases  where  the  labyrinth  is  entirely  destroyed  by  the 
severity  of  the  inflammation. 

Treatment. — The  plan  of  treatment  must  be  decided  by  the  nature 
and  extent  of  the  pathologic  conditions  present  in  the  ear  and  by  the 
length  of  time  that  has  elapsed  since  the  beginning  of  the  disease. 
Prophylaxis  should,  when  opportunity  offers,  play  an  important  part  in 
the  management  of  these  cases.  During  an  attack  of  the  exanthemata  or 
of  the  acute  infectious  disease  the  liability  of  the  general  affection  to  this 
aural  complication  should  not  be  forgotten.  Middle-ear  abscess  should 
be  given  early  and  free  drainage  by  a  free  incision  of  the  drum-head  just 
so  soon  as  the  collection  of  pus  or  other  fluid  is  discovered  in  the  tympanic 
cavity.  Under  such  circumstances  it  is  unwise  to  permit  nature  to  take 
its  course,  to  await  a  rupture  through  the  drum  membrane,  and  the 
subsequent  establishment  of  imperfect  tympanic  drainage.  Provision 
for  a  free  outflow  of  intratympanic  fluids  in  these  cases  will  undoubtedly 
prevent  extension  to  the  labyrinth  in  a  large  proportion  of  those  so 
affected.  If  a  rupture  of  the  membrana  tympani  has  already  occurred 
the  ear  should  be  managed  as  outlined  in  the  chapter  on  Acute  Otitis 
Media  Purulenta,  great  care  being  exerted  to  prevent  mixed  infection, 
and  to  secure  a  free  outflow  of  all  the  nccrotic  inflammatory  products 
until  healing  has  taken  place.  As  a  matter  of  course,  such  general 
medication  should  be  given  as  may  be  indicated  by  the  nature  of  the 
particular  general  ailment,  of  which  the  aural  disease  is  only  a  part. 


INFLAMMATION   OF   THE   LABYRINTH  537 

\Vhen  seen  after  the  general  disease  has  subsided  and  while  the 
middle-ear  affection  is  yet  subacute,  the  internal  remedies  in  which 
most  reliance  can  be  placed  are  potassium  iodid  and  pilocarpin,  the 
proper  mode  of  administering  which  is  stated  on  p.  529.  It  must  be 
anticipated  that  the  worst  cases  will  not  be  improved  greatly,  in  so  far 
as  the  perceptive  portion  of  the  organ  of  hearing  is  concerned,  by  any 
method  of  treatment  yet  devised. 

CHRONIC   OTITIS   INTERNA 

Causation. — Mention  has  already  been  made  of  the  fact  that  during 
the  progress  of  a  chronic  adhesive  inflammation  of  the  middle  ear  or  of 
a  chronic  suppurative  otitis  media  a  secondary  involvement  of  the 
labyrinth  may  take  place.  The  chronic  secondary  inflammatory  state 
of  the  internal  ear  occurs,  therefore,  as  a  result  of  an  extension  of  the 
middle-ear  disease  to  the  capsule  of  the  labyrinth  or  to  the  membranous 
structures  in  which  the  acoustic  nerve  filaments  terminate.  Not  every 
case  of  chronic  dry  middle-ear  catarrh  or  of  suppurative  otitis  media 
is  complicated  by  an  affection  of  the  internal  ear,  but  an  extension  to  the 
perceptive  apparatus,  of  some  degree  of  severity,  probably  occurs  in  the 
course  of  these  affections  much  oftener  than  is  commonly  recognized. 

Symptoms. — The  symptoms  of  chronic  secondary  inflammation  of 
the  labyrinth  are  those  of  mixed  deafness  and  have,  to  some  extent,  been 
described  in  other  chapters.  The  disease  is  distinguished  from  most 
other  internal  ear  affections  by  its  mode  of  onset,  which  is  in  most 
instances  mild  in  the  beginning,  but  progressive  throughout  its  course. 
When  resulting  either  from  dry  middle-ear  catarrh  or  from  suppurating 
otitis  media  the  labyrinthinitis  may  not  develop  for  several  months  or 
even  years  after  the  inception  of  the  tympanic  disease.  Hence,  the 
individual  may  state  that  whereas  he  has  had  a  running  ear  for  several 
years,  that  he  had  only  recently  become  seriously  deaf  and  greatly  dis- 
turbed by  the  incessant  head  noises.  It  is  in  this  particular  form  of 
deafness  that  the  tinnitus  aurium  is  often  most  intolerable.  The  char- 
acter of  these  noises  varies  greatly  in  different  persons  and  at  different 
stages  of  the  disease  in  the  same  person.  The  particular  quality  or 
quantity  of  the  sound  which  is  perceived  by  the  patient  depends,  to  some 
extent  at  least,  upon  the  portion  of  the  labyrinth  most  involved.  Thus, 
when  the  cristae  and  acusticae  are  principally  implicated,  the  tinnitus  may 
be  described  as  a  rumbling,  roaring,  or  booming  noise.  If  the  lower 
turn  of  the  cochlea  is  the  chief  seat  of  the  inflammation  the  noises  are 
most  likely  to  be  high  pitched  and  constant.  The  tinnitus  may  at  first 
be  limited  to  one  ear  and  long  periods  of  complete  cessation  of  the  head 


538     "  THE    PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

noises  may  occur.  As  the  disease  progresses,  however,  the  noises  become 
continuous  and  only  cease  when  the  acoustic  nerve-endings  in  the 
labyrinth  have  become  destroyed  or  are,  at  least,  insensible  .to  sound 
perception.  It  frequently  happens  that  as  soon  as  the  tinnitus  begins 
to  abate  in  the  ear  first  affected  the  opposite  ear  becomes  involved,  and 
rapidly  assumes  a  condition,  both  as  to  the  amount  of  deafness  and  the 
severity  of  the  tinnitus,  which  is  worse  than  that  in  the  original  ear.  In 
the  worst  cases  the  patient,  having  no  respite  from  the  harassing  and 
everpresent  tinnitus,  becomes  finally  despondent,  neurasthenic,  and 
sometimes  suicidal. 

Vertigo  and  nausea  are  frequently  observed,  but  do  not,  as  a  rule, 
occur  so  suddenly  as  in  other  labyrinthine  affections.  These  symptoms 
are  rarely  of  such  severity  as  to  interfere  seriously  with  the  individual's 
locomotion.  In  this,  as  in  other  labyrinthine  affections,  a  disturbance 
of  the  equilibrium  is  usually  regarded  as  an  indication  of  an  implication 
of  the  semicircular  canals,  and  may  be  due  solely  to  an  increased  tension 
of  the  intralabyrinthine  fluids,  the  restoration  of  which  to  the  normal 
restores  the  patient  to  his  usual  static  control. 

Diagnosis. — The  chief  reliance  must  here,  as  in  all  labyrinthine 
affections,  depend  upon  the  results  of  an  accurate  functional  examination. 
The  result  obtained  by  functional  tests  differs  so  little  in  this  and  the 
labyrinthine  inflammation  which  is  secondary  to  acute  middle-ear 
suppuration  that  there  is  no  occasion  to  repeat  here  what  was  said 
concerning  the  same  matter  under  that  heading.  There  is  this  difference, 
however:  In  the  chronic  affection  the  patients  are  usually  adults  and 
there  is  no  severe  general  illness  at  the  time  of  the  examination  to  obtund 
the  intelligence  and  thus  to  interfere  with  the  accuracy  of  the  tests. 
More  accurate  results  should,  therefore,  be  obtained  in  this  instance  as 
a  consequence  of  the  employment  of  these  tests. 

Physical  examination  of  the  drum  membrane  and  middle  ear  shows 
a  variety  of  conditions  dependent  upon  the  cause  of  the  tympanic  affec- 
tion which  has  been  responsible  for  the  spread  of  the  disease  to  the 
inner  ear.  In  case  the  primary  trouble  was  a  chronic  suppurative  otitis 
media  a  great  number  of  pathologic  changes  may  be  discovered,  among 
which  may  be  mentioned  the  presence  of  foul-smelling  pus,  granulations 
or  polypi,  perforation  or  destruction  of  the  membrana  tympani,  complete 
absence  or  partial  necrosis  of  one  or  more  ossicles,  and  necrosis  of  the 
mucous  membrane  of  the  tympanic  cavity  with  exposure  and  caries  of 
some  portion  of  the  osseous  walls  of  the  middle  ear. 

Should  the  labyrinthine  involvement  be  secondary  to  an  adhesive 
middle-ear  catarrh  the  drum  membrane  may  appear  normal  in  every 


INFLAMMATION    OF   THE    LABYRINTH  539 

particular  or  it  may  be  alternately  thickened  and  atrophic  over  different 
areas.  Retraction  of  the  drum-head,  with  ossicular  displacement, 
adhesion,  and  ankylosis  of  the  ossicular  chain  are  commonly  observed. 
The  membrana  tympani  is  at  times  thickened,  opaque,  and  milk  white 
in  appearance;  the  landmarks  are  more  or  less  obliterated  and  both 
ossicular  chain  and  membrane  are  absolutely  immovable  to  the  suction 
of  Siegle's  otoscope. 

Prognosis. — When  labyrinthine  inflammation  is  secondary  to 
a  suppurative  otitis  media  the  prognosis  is,  as  a  rule,  more  favorable 
than  when  it  occurs  subsequently  to  a  hyperplastic  otitis  media.  In 
other  instances  the  involvement  of  the  perceptive  portion  of  the  ear  may 
be  arrested,  to  some  extent  at  least,  provided  the  opportunity  to  treat 
the  disease  is  given  sufficiently  early.  When  observed  in  connection 
with  any  variety  of  middle-ear  disease  which  has  been  of  long  standing, 
and  especially  if  there  has  been  considerable  necrosis  of  the  soft  or 
osseous  structures,  or  if  there  has  been  much  deposit  of  new  connective 
tissue  in  the  middle  ear,  a  correspondingly  great  change  in  the  labyrinth 
may  be  inferred,  and  the  prognosis  may,  therefore,  be  regarded  as  very 
unfavorable.  In  those  instances  in  which  new  tissue  has  been  deposited 
in  the  capsule  and  the  spaces  of  the  labyrinth  have  thereby  been  narrowed 
or  obliterated,  the  acoustic  nerve-endings  are  destroyed  and  any  favor- 
able termination  is  therefore  impossible.  The  prognosis,  in  cases  where 
one  ear  is  seriously  involved  and  the  other  not  at  all  or  but  slightly,  is 
usually  unfavorable  for  both  the  better  as  well  as  the  bad  ear,  because 
the  history  of  such  cases  shows  that  the  better  ear  is  sooner  or  later 
attacked  and  is  often  more  rapidly  impaired  than  was  the  first.  In  such 
instances  the  prognosis  may  be  more  favorable  if  the  case  is  seen  early 
and  a  proper  line  of  treatment  is  promptly  instituted. 

Treatment. — Since  no  known  treatment  is  capable  of  bringing 
about  satisfactory  results  after  once  the  disease  is  very  chronic  and 
extensive  tissue  changes  have  taken  place  both  in  the  middle  ear  and 
labyrinth,  it  should,  therefore,  be  borne  in  mind  that  all  suppurative  or 
hyperplastic  processes  of  the  tympanum  should  receive  appropriate 
attention  at  the  earliest  possible  time.  Purulent  otitis  media,  together 
with  all  its  evil  consequences — necrosis  of  soft  and  osseous  structures, 
granulations,  polypi,  etc. — should  be  managed  in  its  incipiency  accord- 
ing to  plans  of  treatment  already  given  for  these  conditions  (see  Chapter 
XXVIII.).  Likewise,  the  first  stages  of  the  adhesive  catarrhal  pro- 
cesses in  the  tympanic  cavity  should  be  treated  so  soon  as  discovered. 
Prophylaxis,  therefore,  should  be  regarded  as  the  best  possible  treatment 
for  this  as  for  many  other  aural  affections,  and  every  child  or  young  adult 


540  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

who  has  nasal  or  nasopharyngeal  growths  that  interfere  with  free  res- 
piration and  invite  frequent  inflammation  must  be  regarded  as  an 
individual  who  is  very  likely  to  develop  middle-ear  disease,  with  possibly 
a  subsequent  labyrinthine  inflammation.  Attention  to  the  diseases  of 
the  upper  air  tract  in  early  life  would  undoubtedly  eliminate  many  of 
the  possibilities  of  later  aural  affection,  and  early  rhinologic  treatment, 
when  necessary,  is  of  greater  value  to  the  child  than  any  attention, 
however  skilfully  applied,  which  may  be  instituted  after  the  organ  of 
hearing  is  chronically  diseased  or  perhaps  hopelessly  destroyed. 


CHAPTER  XLV 
LABYRINTHINE   SYPHILIS 

SPECIFIC  involvement  of  some  portion  of  the  labyrinth  or  of  the 
nervous  mechanism  supplying  it  constitutes  one  of  the  most  frequent 
forms  of  primary  disease  of  the  perceptive  apparatus,  and  may  result 
either  from  hereditary  or  acquired  syphilis.  Packard  (Jour.  Amer. 
Med.  Assoc.,  June  15,  1901)  found  4  cases  of  this  affection  in  a  total  of 
2500  consecutive  cases  of  ear  disease. 

Symptoms. — These  have  many  points  in  common  with  those  occur- 
ring from  other  diseases  of  the  labyrinth,  among  which  are  sudden  and 
often  complete  deafness  in  one  or  both  ears,  vertigo,  tinnitus  aurium, 
and  sometimes  nausea.  No  symptom  is,  therefore,  pathognomonic  of 
the  specific  complication  of  the  ear.  In  the  hereditary  form  of  the 
disease  the  deafness  comes  on  more  slowly  and  is  frequently  accompanied 
by  inflammatory  and  ulcerative  inflammations  of  the  eye,  which  latter 
are  also  of  syphilitic  origin. 

Diagnosis. — The  diagnosis  is  seldom  made  except  as  a  result  of  the 
more  rigid  physical  examination  of  the  body  in  general,  and  of  the  nose 


FIG.  301.— PARENT.  FIG.  302.— CHILD  FIVE  YEARS  OLD. 

and  throat  and  eye  and  ear  in  particular  (Figs.  301  and  302).  Since 
the  affection  comes  on  either  during  the  secondary  or  tertiary  stages  of 
the  syphilis  it  is  usually  possible  to  discover  some  evidences  of  a  specific 
nature  upon  the  skin,  upon  the  mucous  membrane  of  the  upper  air 
tract,  or  in  the  structure  of  the  eye.  In  the  case  of  any  individual, 
therefore,  who  is  suddenly  attacked  by  severe  labyrinthine  symptoms 

541 


542  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

the  skin  should  be  inspected  for  the  purpose  of  determining  the  pres- 
ence of  syphilis.  Mucous  patches  may  be  found  in  the  mouth,  over 
the  soft  palate,  or  upon  the  tonsils  if  there  is  present  a  syphilis  in  the 
secondary  stage,  whereas  if  it  has  progressed  to  the  tertiary  stage,  any 
portion  of  the  hard  or  soft  palate,  the  tonsils,  or  the  postpharyngeal 
wall  may  be  found  swollen  and  red  from  the  presence  of  a  gumma ;  or 
the  gumma  may  have  already  broken  down,  after  which  deep  ulceration 
or  even  perforation  of  the  hard  or  soft  palate  may  be  seen  as  a  result. 
The  author  has  observed  one  case  of  labyrinthine  deafness  due  to 
syphilis,  the  sole  objective  evidence  of  which  was  found  in  an  ulcerated 
condition  of  the  epiglottis.  The  nose  likewise  furnishes  frequent  evi- 
dence of  tertiary  syphilis  when  no  other  part  of  the  body  suggests  its 
presence.  Thus,  the  nasal  septum  may  be  found  swollen  from  a  gumma 
or  it  may  be  widely  perforated  or  even  completely  destroyed  by  the 
disease.  The  external  deformity  known  as  "saddle-back"  nose  is  most 


FIG.  303. — HUTCHINSON  TEETH  OF  CHILD. 
Note  irregular  setting  and  indentations  of  each  tooth. 

often  due  to  syphilis.  In  addition  to  the  above  physical  evidences  of 
specific  infection,  the  presence  of  enlarged  lymphatics  in  the  cervical, 
axillary,  or  inguinal  regions  may  furnish  helpful  diagnostic  information. 
Children  who  suffer  from  labyrinthine  deafness  as  a  consequence  of 
hereditary  syphilis  are  not  suddenly  seized  by  the  aural  symptoms,  as 
is  the  case  in  adults  when  following  the  acquired  variety.  The  diagnosis 
of  the  nature  of  the  labyrinthine  affection  in  this  class  will  usually  be 
based  upon  the  syphilitic  history  of  the  parent  and  upon  the  evidences 
of  the  syphilis  itself  as  exhibited  by  corneal  opacities  or  active  ulceration 
of  the  cornea,  and  upon  the  presence  of  the  peculiar  arrangement  and 
shape  of  the  teeth,  generally  spoken  of  as  the  Hutchinson  teeth  (Fig. 

303). 

Since  suppurative  otitis  media  sometimes  coexists  with  the  syphilitic 
affection  of  the  labyrinth,  the  symptoms  due  to  the  latter  may  be  attrib- 
uted entirely  to  the  middle-ear  disease  unless  a  differentiation  is  made 
by  means  of  functional  tests  with  the  tuning-forks.  It  should  be  remem- 


LABYRINTHINE    SYPHILIS  543 

bered  that  in  case  of  specific  diseases  of  the  labyrinth,  as  in  all  other 
ailments  involving  the  perceptive  apparatus,  that  air  conduction  for  the 
vibrating  C  fork  will  probably  be  better  in  the  worse  ear  than  bone 
conduction  (Rhine  — );  that  when  the  vibrating  fork  is  placed  upon  the 
center  line  of  the  skull  it  is  usually  heard  longest  in  the  better  ear,  and 
that  the  high  tones,  especially  those  above  C3,  are  often  not  heard  at  all. 

Examination  of  the  fundus  of  the  ear  in  most  cases  of  labyrinthine 
disease  due  to  syphilis  shows  a  healthy  drum  membrane,  and  unless 
a  nasopharyngitis  is  present  the  Eustachian  tube  will  be  found  patent 
when  catheter  inflation  is  practised. 

Politzer  (Diseases  of  the  Ear)  states  that  labyrinthine  syphilis  may 
occur  without  the  presence  of  any  other  symptom  of  a  general  infection 
being  discoverable  at  the  time.  However,  a  thorough  examination  of 
the  skin,  the,upper  respiratory  tract,  and  the  eyes  of  any  suspected  case 
will  usually  enable  the  diagnostician  to  find  sufficient  evidence  of  syphilis 
to  justify  a  diagnosis  of  specific  labyrinthinitis  in  any  case  where  this 
disease  has  been  the  primary  cause  of  the  internal  ear  affection. 

Prognosis. — Should  the  labyrinthine  affection  be  of  acquired 
variety  and  of  only  short  duration,  the  prognosis  is  somewhat  favorable, 
at  least  in  so  far  as  improvement  of  the  deafness,  tinnitus,  and  vertigo 
is  concerned.  Cases  of  long  standing,  which  have  progressed  unhindered 
by  proper  treatment,  particularly  if  in  persons  of  debilitated  habit  or  of 
advanced  age,  are  likely  to  grow  worse  despite  any  form  of  treatment. 
The  prognosis  is  also  bad  should  there  have  previously  existed  an 
adhesive  catarrhal  otitis  media  or  a  suppurative  otitis.  Inherited 
labyrinthine  syphilis  is  more  unfavorable  in  its  prognosis  than  is  the 
acquired  variety,  the  disease  being  often  of  a  progressive  nature  and 
continuing  until  total  deafness  results. 

Treatment. — Specific  labyrinthine  deafness  should  be  treated  at 
the  earliest  possible  moment  by  the  administration  of  those  drugs  most 
suited  to  the  particular  stage  of  the  syphilis  in  which  the  labyrinthine 
disturbance  occurs.  Should  the  deafness  and  dizziness  appear  during 
the  secondary  stage  both  mercury  and  the  iodids  are  indicated,  the 
former  being  given  until  its  full  physiologic  effect  is  produced,  whereas 
the  latter  may  be  administered  in  moderate  doses.  On  the  other  hand, 
when  labyrinthine  symptoms  rapidly  develop  during  the  tertiary  period, 
the  iodids  accomplish  a  better  purpose  than  the  mercury,  and  hence 
should  be  pushed  even  to  the  administration  of  3  or  4  dr.  of  the  drug 
in  the  twenty-four  hours.  In  this  stage  mercury  is  secondary  in  value 
to  the  iodids,  but  may  be  given  in  the  form  of  an  iodid  or  bichlorid, 
especially  if  for  any  reason  the  iodids  of  potassium  or  sodium  are  badly 


544  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

borne.  Mercurial  inunctions  also  provide  a  good  means  of  giving 
mercurials  and  have  the  decided  advantage  of  saving  the  stomach  for 
the  administration  of  the  more  important  iodids  of  potassium  or  sodium. 

Specific  medication  is  not  so  effective  in  the  treatment  of  hereditary 
syphilis  and  consequently  not  of  the  labyrinth  complication.  Syphilitic 
children  do  better  when  care  is  given  to  secure  their  best  nourishment 
and  to  insure  for  them  a  maximum  of  time  to  be  spent  in  the  open  air 
and  sunshine.  Ferruginous  tonics  and  cod-liver  oil  are  helpful  in  the 
badly  nourished  cases. 

Local  treatment  of  the  ears  in  any  variety  of  syphilitic  inflammation, 
except  in  those  suffering  from  a  coexisting  middle-ear  disease,  is  useless 
and  probably  harmful. 


CHAPTER  XLVI 


REFERENCE  has  many  times  been  made  in  the  several  chapters  of 
this  work  to  the  effect  upon  the  hearing  produced  by  certain  constitu- 
tional diseases,  chiefly  those  of  an  infectious  character.  Among  the 
general  diseases  that  are  most  likely  to  be  accompanied  or  followed  by 
an  aural  complication  are  the  exanthemata,  especially  scarlatina  and 
measles,  epidemic  cerebrospinal  meningitis,  meningitis,  typhus  and 
typhoid  fever,  mumps,  syphilis,  and  influenza.  All  these  affections  may 
seriously  impair  or  even  completely  destroy  the  function  of  the  labyrinth. 
They  may  attack  the  labyrinth  in  the  following  ways:  (a)  The  systemic 
infection,  of  whatever  nature  it  may  be,  may  act  directly  upon  the 
labyrinthine  structures  solely  through  the  blood  supply  to  this  portion 
of  the  ear;  (6)  pathogenic  material  may  be  transported  from  an  infective 
or  suppurative  disease  of  the  cerebrum  or  cerebellum  to  the  labyrinth, 
through  the  intercommunicating  blood  and  lymph  canals,  or  the  infection 
may  take  place  more  directly  through  either  the  vestibular  or  cochlear 
aqueducts;  (c)  the  labyrinthine  implication  may  be  secondary  to  a 
tympanic  suppuration,  in  which  case  the  infection  usually  finds  its  way 
inward  into  the  labyrinth,  through  the  common  blood  supply  of  these 
two  divisions  of  the  hearing  apparatus.  On  the  other  hand,  the  pus 
may  enter  the  vestibule  or  cochlea  directly  from  the  middle  ear  through 
a  perforation  in  the  inner  tympanic  wall,  which  has  resulted  from  an 
osseous  necrosis. 

Chief  among  the  general  diseases  which  affect  the  labyrinth  through 
an  extension  of  some  infection  from  the  brain  coverings,  the  several 
forms  of  meningitis,  including  epidemic  cerebrospinal  meningitis,  should 
be  mentioned.  The  labyrinth  is  perhaps  most  commonly  infected 
through  the  medium  of  the  blood-current  in  typhoid  and  typhus  fever, 
mumps,  and  syphilis.  Labyrinthine  complications  when  secondary  to 
middle-ear  suppuration  may  follow  a  number  of  diseases,  chief  among 
which  are  scarlet  fever,  measles,  la  grippe,  infective  tonsillitis,  and 
diphtheria. 

35  545 


546  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

Epidemic  cerebrospinal  meningitis  is  frequently  followed  by 
disease  of  the  labyrinth  and  consequently  by  an  impairment  of  function 
which  sometimes  amounts  to  total  deafness.  Beginning  at  about  the 
end  of  the  second  week  of  the  disease  the  infective  inflammation  of  the 
meninges,  which  characterizes  the  primary  disease,  may  extend  into  the 
internal  auditory  meatus,  along  the  sheaths  of  the  facial  and  auditory 
nerves,  and  finally  implicate  the  various  structures  comprising  the 
internal  ear.  Instead  of  inflammation  traveling  from  the  meninges  to 
the  labyrinth  by  this  route,  actual  pus  from  the  meninges  may  take  its 
way  along  the  same  path  into  the  labyrinth.  Likewise  an  inflammation 
or  the  actual  products  of  suppuration  may  enter  the  labyrinth  through 
one  of  the  aqueducts. 

The  symptoms  of  the  labyrinthine  complication,  when  arising  during 
the  process  of  the  cerebrospinal  meningitis,  are  in  the  beginning  the 
sudden  onset  of  more  or  less  deafness,  accompanied  by  pain  in  the  ear 
and  tinnitus  aurium.  These  symptoms  may  rapidly  increase  in  severity 
until  a  high  degree  of  deafness  or  even  total  deafness  results.  Should 
the  patient  be  unconscious  or  even  much  stupid  at  the  time  the  labyrinth 
is  so  involved,  the  presence  of  the  above  symptoms  will  not  be  known 
until  sufficient  mentality  has  been  restored  to  the  patient  to  enable  him 
to  recognize  the  defect. 

The  deafness  due  to  this  cause  is  usually  bilateral  and,  in  case 
recovery  from  the  meningitis  results,  is  accompanied  by  intense  tinnitus 
aurium  and  disturbed  equilibrium,  the  latter  sometimes  being  present 
to  the  extent  that  walking  is  impossible.  When  the  degree  of  deafness 
is  total  the  head  noises  usually  subside  and  the  unsteadiness  of  gait  in 
time  improves  and  finally  disappears.  The  facial  nerve  is  sometimes 
injured  by  the  disease  during  its  passage  through  the  internal  auditory 
meatus,  and  as  a  result  facial  paralysis  is  added  to  the  patient's  list  of 
misfortunes,  which  may  also  include  blindness  and  the  arrest  of  devel- 
opment or  total  suspension  of  mentality.  In  young  individuals  deaf- 
mutism  is  a  common  sequence,  even  in  cases  in  which  the  cerebrospinal 
meningitis  was  not  severe. 

The  prognosis  in  deafness  due  to  this  disease  is  unfavorable  for  the 
reason  that  the  damage  wrought  to  the  labyrinthine  structures  is  of  such 
nature  that  restoration  is  impossible.  The  outlook  for  improvement  in 
the  hearing  is  regarded  as  better  in  those  cases  in  which  the  disease  is 
accompanied  by  tinnitus  aurium,  for,  so  long  as  the  head  noises  are 
perceived,  this  fact  furnishes  evidence  that  at  least  some  portion  of  the 
organ  of  Corti  is  still  intact. 

Treatment  of  this  form  of  deafness  is  usually  of  little  consequence. 


LABYRINTHINE   DISEASES   DEPENDENT   UPON   GENERAL   AFFECTIONS    547 

If  the  labyrinthine  involvement  is  recognized  at  the  moment  of  its  onset 
during  the  progress  of  the  meningitis,  the  aural  ice-bag  should  be  applied 
to  one  or  both  mastoid  processes  and  kept  on  for  two  or  three  days 
without  intermission,  while  at  the  same  time  all  other  symptoms  of  the 
meningitis  are  met  by  means  most  appropriate  to  the  individual  case. 
During  convalescence  an  effort  should  be  made  to  absorb  the  exudates 
that  have  presumably  been  left  in  the  labyrinth,  and  this  can  best  be  done 
by  the  administration,  first,  of  pilocarpin  and,  later,  of  the  iodids  of 
sodium  and  potassium.  If  a  child,  and  the  resulting  deafness  is  too 
great  to  permit  hearing  for  the  speaking  voice,  the  patient  should  be  sent 
to  an  institution  for  the  education  of  the  deaf  so  soon  as  the  proper  age 
is  attained. 

Constitutional  Diseases  which  May  Implicate  the  Labyrinth 
Chiefly  through  an  Infection  by  the  Blood  Supply  to  the  Inner 
Ear. — The  diseases  included  in  this  classification  may  also  rarely 
cause  middle-ear  suppuration,  the  particular  pathogenic  bacteria  of  the 
disease  finding  their  way  into  the  middle  ear  through  the  Eustachian 
tube  (see  Chapter  on  Bacteriology). 

Typhus  and  Typhoid  Fever.— During  the  progress  of  these  diseases 
it  is  frequently  observed  that  deafness  in  some  degree — often  very  severe — 
has  occurred.  This  may  sometimes  be  attributed  to  the  impaired  and 
often  almost  completely  suspended  mentality  of  the  patient  which  is 
present  as  a  result  of  the  direct  action  upon  the  cerebrum  of  the  specific 
poison  of  the  typhoid  or  typhus  state.  When  the  deafness  is  due  to  this 
cause,  improvement  in  the  hearing  takes  place  subsequently  and  coinci- 
dent with  the  convalescence  from  the  primary  disease.  Instances  are, 
however,  met  with  in  which  marked  deafness  and  tinnitus  persist  indefi- 
nitely after  recovery  from  the  specific  fever,  and  the  functional  tests  in 
such  cases  point  unmistakably  to  an  involvement  of  the  labyrinth.  In 
nearly  all  such  cases  an  objective  examination  of  the  drum  membrane 
and  middle  ear  shows  nothing  abnormal. 

The  prognosis  is  unfavorable.  Local  treatment  is  usually  without 
effect  upon  the  hearing  and  the  internal  administration  of  strychnin  and 
other  nerve  stimulants  offers  the  best  chance  of  improvement,  which, 
under  all  circumstances,  is  likely  to  be  but  slight. 

Mumps. — The  tendency  of  mumps  toward  a  metastatic  involvement 
of  the  testes,  ovaries,  and  breasts  is  well  known,  and  an  explanation  of 
the  occurrence  of  deafness  during  an  attack  of  parotitis  has  been  made 
upon  similar  grounds.  Whatever  the  nature  of  the  virus  of  mumps 
may  be,  in  the  purely  labyrinthine  cases  of  deafness  which  result  from 
its  deposit  in  the  inner  ear,  the  effect  seems  most  often  to  be  upon  the 


548  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

auditory  nerve  itself,  and  to  finally  cause  more  or  less  complete  atrophy 
of  its  trunk. 

The  symptoms  are  the  onset,  during  the  first  week  of  the  mumps, 
of  deafness  which  is  more  or  less  profound,  together  with  the  occurrence 
of  tinnitus  aurium  and  sometimes  a  staggering  gait.  Both  ears  are 
affected  in  about  one-half  of  all  cases.  Adults  are  as  frequently  affected 
as  children.  Pain  in  the  ear  is  uncommon  and  usually  little  or  no 
fever  is  present,  except  the  same  be  due  to  the  mumps  itself.  Sometimes 
the  deafness  precedes  the  swelling  of  the  parotid  glands.  The  laby- 
rinthine complication  of  mumps  is  much  more  frequent  in  some  epi- 
demics than  in  others. 

The  diagnosis  can  be  made  from  the  known  tendency  of  mumps 
to  affect  the  perceptive  portion  of  the  ear  and  by  means  of  the  tuning- 
forks,  which  will  show  that,  whereas  the  hearing  is  greatly  impaired, 
bone  conduction  will  be  very  poor,  and  in  the  worst  cases  the  vibration 
will  not  be  heard  at  all  through  the  bone.  Upon  otoscopic  examination 
it  will  usually  be  seen  that  the  drum  membrane  is  normal  in  every  re- 
spect, and  by  catheter  inflation  it  may  be  demonstrated  that  the  normal 
patency  of  the  Eustachian  tube  has  in  nowise  been  disturbed. 

The  prognosis  in  this,  as  in  most  other  affections  of  the  labyrinth, 
is  not  very  hopeful.  Except  in  the  early  stages  of  the  complication 
and  in  the  mildest  cases  treatment  has  little  effect  in  restoring  the  hearing. 
The  best  results  are  obtained  by  tonic  and  restorative  methods.  If 
increased  labyrinthine  pressure  is  indicated  by  the  presence  of  severe 
tinnitus  and  disturbed  equilibrium  and  the  patient  is  plethoric,  the 
administration  of  saline  purgatives  and  pilocarpin  will  prove  most 
effective  in  the  absorption  of  the  excessive  labyrinthine  exudates  and 
consequently  in  the  restoration  of  function. 

Syphilis. — The  affect  of  this  disease  upon  the  labyrinth  has  already 
been  considered  (see  Chapter  XLV.). 

General  Diseases  which  Secondarily  Affect  the  Labyrinth 
through  First  Establishing  a  Suppurative  Otitis  Media. — To 
this  class  belong  the  exanthameta,  especially  scarlet  fever  and  mea- 
sles; certain  infective  general  diseases,  as  diphtheria  and  la  grippe; 
certain  throat  inflammations  and  infections,  as  the  different  forms 
of  tonsillitis.  The  pathogenic  bacteria  which  aie  present  in  the  pharynx 
and  nasopharynx  during  the  progress  of  these  several  affections  find 
entrance  through  the  Eustachian  tube  into  the  middle  ear,  where  a 
violent  inflammation  and  speedy  suppuration  is  at  once  set  up.  In  a 
considerable  percentage  of  these  cases  of  otitis  media  suppurativa  the 
septic  products  find  their  way  into  the  labyrinth  either  through  an 


opening  the  result  of  a  previous  necrosis  of  the  intervening  osseous 
structures  or  by  transportation  of  the  pathogenic  bacteria  through  the 
blood  or  lymph  channels.  In  either  case  extensive  damage  is  done 
to  the  perceptive  portion  of  the  ear  and  total  deafness  may  be  the  con- 
sequence (see  Chapter  XLVIIL).  Since  the  various  diseases  named 
under  this  head  act  first  and  chiefly  upon  the  tympanic  structures,  a 
more  complete  consideration  of  their  relation  to  aural  diseases  is  given 
in  another  section  of  the  work  (see  Chapter  XXIV.)- 


CHAPTER  XLVII 

LABYRINTH  SUPPURATION  WITH  CARIES  AND  NE- 
CROSIS OF  THE  PETROUS  PORTION  OF  THE  TEM- 
PORAL BONE 

INFECTION  and  subsequent  suppuration  within  the  several  channels 
and  cavities  comprising  the  labyrinth  is  now  known  to  occur  with 
considerable  frequency.  Greater  attention  to  diagnostic  methods 
in  the  examination  of  the  middle  ear,  together  with  more  frequent  and 
extensive  operations  upon  the  temporal  bone  for  the  cure  of  suppurative 


External  audi- 
tory meatus 


FIG.  304. — COMPOUND  FRACTURE  OF  PETROUS  PORTION  OF  THE  TEMPORAL  BY  LEAD  BULLET. 
(Warren  Museum,  Harvard  Medical  School.     J.  Orne  Green  Collection.) 

diseases  within,  have  not  only  demonstrated  the  frequency  of  internal 
ear  suppuration  but  have  also  stimulated  operators  to  greater  activity 
in  determining  the  correct  methods  of  cure.  Indeed  the  successful 
invasion  of  the  labyrinth  by  surgical  means  may  be  classed  among 
the  greatest  of  the  many  recent  achievements  of  operative  otology.  The 
cause  of  such  suppuration  may  be  a  previously  existing  middle-ear 

550 


SUPPURATION   WITH    CARIES   AND    NECROSIS    OF   TEMPORAL    BONE   551 

discharge,  or  it  may  result  from  severe  injuries  which  cause  fracture 
of  the  temporal  bone,  as  in  Figs.  304  and  305. 

Symptoms.— The  subjective  symptoms  of  an  infection  and  subse- 
quent suppuration  of  the  labyrinth  are  of  themselves  but  little  or  not  at 
all  different  from  those  occurring  when  the  middle  and  inner  ear  are 
involved  from  other  causes.  The  patient  complains  of  deafness,  aural 
discharge,  dizziness,  some  degree  of  tinnitus,  pain,  and  frequently  of 
facial  paralysis.  The  deafness  may 
appear  suddenly  in  the  course  of 
what  is  believed  to  be  an  ordinary 
case  of  suppurative  otitis  media  and 
may  vary  in  degree  from  a  moderate 
impairment  to  a  total  inability  to 
hear.  The  affection  is  usually  uni- 
lateral. Head  noises  are,  as  a  rule, 
less  troublesome  in  this  disease  than 
in  other  affections  of  the  inner  ear, 
possibly  for  the  reason  that  the 
auditory  nerve  terminals  were  in 
the  beginning  of  the  disease  de- 
stroyed. When  the  semicircular 
canals  are  involved  the  amount  of 
vertigo  may  be  so  great  as  to  compel  FlG-  3°s-~ CASE  OF  TRACMATIC  MASTOIDITJS, 

LABYRINTHINE    SUPPURATION,   TOTAL   DEAFNESS 
the   patient   tO  remain  for    a    COnSld-      IN  INJURED  EAR,  AND  FACIAL  PARALYSIS  ON  AF- 

erable  time  in  a  recumbent  position. 

Pain  is  present  on  the  affected  side  when  the  labyrinthine  suppura- 
tion has  been  of  such  severe  character  as  to  cause  caries  or  necrosis  of 
some  part  of  the  petrous  portion  of  the  temporal  bone.  When  a  seques- 
trum is  forming  and  during  the  process  of  its  separation  and  expulsion 
there  is  of  necessity  much  irritation  or  actual  injury  to  the  sensory 
nerves  supplying  the  parts,  and  as  an  inevitable  result  more  or  less  pain 
is  present,  and  severe  hemorrhage.  The  pressure  resulting  from  the 
excessive  growth  of  granulation  tissue  or  polypi  from  the  environment 
of  the  sequestra  is  also  responsible  for  the  pain  in  many  cases. 

Facial  paralysis  is  a  symptom  of  nearly  all  cases  of  labyrinth  infec- 
tion in  which  there  is  subsequent  suppuration  and  necrosis.  The 
location  of  the  facial  nerve  in  its  tortuous  course  through  the  petrous 
bone  would  render  its  injury  an  almost  certainty  in  every  case  of  exten- 
sive necrosis  and  sequestra  of  the  labyrinth.  Of  35  cases  of  labyrinth 
suppuration  and  necrosis  reported  by  Bezold,  there  was  only  partial 
facial  paralysis  in  6;  whereas  in  the  remainder  there  was  a  very  decided 


552  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

paralysis.  Should  the  necrosis  of  the  petrous  portion  occur  at  the 
internal  meatus  both  the  facial  and  auditory  nerves,  because  of  their 
intimate  relation  at  this  point,  are  almost  certain  to  be  destroyed,  in 
which  instance  total  deafness  and  complete  facial  paralysis  will  simul- 
taneously result. 

Diagnosis. — Physical  Examination. — Because  of  the  long-continued 
suppuration  the  patient  is  sometimes  septic,  and  this,  together  with 
the  pain  and  loss  of  sleep,  may  give  the  individual  a  worn  and  haggard 
look.  When  absorption  of  pathogenic  products  has  taken  place  or 
when  there  has  been  an  extension  of  the  disease  to  the  meninges,  both 
the  pulse  and  temperature  may  be  increased.  Inspection  of  the  auditory 
canal  and  middle  ear  will  detect  the  aural  discharge.  The  drum  mem- 
brane will  be  perforated  and  perhaps  largely  destroyed.  Granulations 
or  polypi  are  frequently  present,  sometimes  to  the  extent  of  filling  the 
tympanic  cavity  and  external  auditory  meatus.  All  the  physical  changes 
in  the  tympanic  cavity  that  were  described  in  the  chapters  on  Chronic 
Purulent  Otitis  Media  and  Chronic  Mastoiditis  may  be  found  present 
in  this  disease.  In  fact,  mastoiditis  and  suppuration  and  necrosis  of 
the  labyrinth  are  so  often  associated  in  the  same  case  that  every  effort 
should  be  made  during  the  examination  of  any  case  of  discharge  from 
the  middle  ear  to  determine  if  the  suppurative  path  has  been  toward 
the  mastoid  or  toward  the  petrous  portion  of  the  temporal  bone;  and 
when  the  intratympanic  exploration  has  been  thorough,  it  is  sometimes 
found  that  both  portions  of  the  temporal  bone  have  been  involved. 

The  methods  of  making  this  examination  have  already  been  de- 
scribed and  need  not  be  repeated  here  (see  Chapter  XXVI.).  Should 
exfoliation  of  some  portion  or  the  whole  of  the  labyrinth  already  have 
occurred,  the  sequestrum  may  be  discovered  by  the  probe  as  a  loose  mass 
of  bone  embedded  in  the  surrounding  granulations.  The  sequestra  thus 
thrown  off  may  vary  in  size  from  that  representing  the  whole  labyrinth 
to  that  which  includes  only  the  cochlea  or  one  semicircular  canal.  In 
the  former  instance  the  separated  mass  would  be  too  large  to  find  its 
way  outward  through  the  external  auditory  meatus;  whereas  if  only  the 
cochlea  or  one  of  the  semicircular  canals  is  thrown  off,  the  same  may 
be  found  lying  loosely  in  the  tympanic  cavity  or  even  in  the  external 
auditory  meatus,  from  which  it  is  ultimately  discharged  or  extracted. 

Prognosis. — Considering  the  fact  that  the  labyrinth  is  surrounded  on 
two  sides  by  dura  mater  and  that  the  carotid  artery  and  petrosal  sinuses 
pass  respectively  through  the  petrous  portion  of  the  bone  and  lie  in 
immediate  contact  with  it,  it  seems  rather  remarkable  that  suppuration 
and  necrosis  within  the  labyrinth  is  not  followed  by  a  greater  fatality 


SUPPURATION   WITH    CARIES   AND   NECROSIS   OF   TEMPORAL   BONE   553 

than  is  indicated  by  statistics.  In  the  cases  reported  by  Bezold  death 
occurred  in  about  20  per  cent.,  the  cause  of  death  being  due  usually  to 
an  extension  of  the  infection  to  the  meninges.  In  those  in  which 
spontaneous  recovery  took  place  there  was  an  exfoliation  of  the  whole  or 
some  portion  of  the  labyrinth,  with  subsequent  discharge  of  the  seques- 
trum through  the  external  auditory  meatus,  and  in  one  case  through 
the  Eustachian  tube  into  the  nasopharynx.  In  several  of  the  cases  cure 
followed  some  form  of  mastoid  operation  which  provided  a  channel 
sufficiently  wide  to  permit  the  extraction  of  the  exfoliated  labyrinth. 
Following  a  complete  exfoliation  of  the  labyrinth  healing  of  the  result- 
ing cavity  takes  place  either  by  means  of  the  cavity  filling  with  granu- 
lation and  osseous  tissue  or  by  an  extension  into  it  of  the  epidermis  from 
the  external  auditory  meatus,  by  which  the  space  is  ultimately  lined  by  a 
dermoid  layer  and  finally  becomes  dry. 

The  prognosis  as  to  function  is  bad,  since  if  the  cochlea  is  necrosed 
and  exfoliated  the  auditory  nerve  terminals  are  completely  and  per- 
manently destroyed.  In  case  only  the  semicircular  canals  are  thrown 
off  and  the  labyrinth  is  left,  a  considerable  degree  of  hearing  may  re- 
main. The  facial  nerve  possesses  remarkable  power  of  regeneration 
and  hence,  if  the  trunk  has  only  been  injured  through  pressure  or  but 
a  short  portion  of  its  course  is  destroyed,  it  is  probable  that  more  or 
less  complete  restoration  will  take  place,  and  motion  will  be  again 
possible  in  the  paralyzed  facial  muscles.  Should,  however,  a  consider- 
able portion  of  the  Fallopian  canal  be  swept  away,  and  with  it  the 
contained  portion  of  the  trunk  of  the  facial  nerve,  it  is  entirely  improbable 
that  the  nerve  will  be  regenerated  or  that  the  facial  paralysis  will  ever 
be  improved  (see  Chapter  XXX.). 

Treatment. — The  treatment  of  this  disease  is  wholly  surgical. 
In  the  earlier  stages,  when  the  diagnosis  remains  doubtful,  the  method 
of  treatment  advocated  for  suppurative  otitis  media  should  be  employed. 
When  seen  at  a  later  period,  and  the  external  auditory  meatus  is  found 
filled  with  granulations  or  polypi,  it  may  be  necessary  to  remove  these 
by  means  of  a  snare  or  curet  before  it  is  possible  to  determine  the  presence 
of  a  labyrinthine  suppuration  or  necrosis,  and,  therefore,  before  a  plan 
of  operative  treatment  can  be  outlined.  Since  the  surgery  of  the  laby- 
rinth is  always  best  performed  in  connection  with  the  radical  mastoid 
operation,  the  reader  is  referred  to  the  chapter  which  deals  with  this 
latter  procedure  (see  Chapter  XXX.). 


CHAPTER  XL VIII 
DEAF-MUTISM 

Definition. — This  term  is  applied  to  individuals  who,  because  of  an 
early  inability  to  hear  spoken  language,  are  both  deaf  and  dumb.  Deaf- 
mutism  may  be  either  congenital  or  acquired.  In  case  of  acquired  deaf- 
mutism  the  child  may  have  lost  the  hearing  before  the  age  when  speech 
is  normally  learned;  or  in  older  children  some  degree  of  child  language 
may  have  been  acquired  before  the  damage  to  the  ears  has  occurred,  but 
this  is  afterward  lost  because  it  can  be  no  longer  heard  or  practised.  In 
the  case  of  children  who  have  lost  the  hearing  power  as  late  as  the  age  of 
eight  or  ten,  it  is  probable  that  ability  to  speak  such  language  as  has 
already  been  learned  will  to  some  extent  be  indefinitely  retained.  In 
such  instances,  however,  the  patient,  no  longer  hearing  the  sound  of  the 
words,  ultimately  forgets  both  their  combination  of  tone  and  accent  and 
is,  therefore,  no  longer  able  to  pronounce  them  with  distinctness;  in  many 
instances  the  speech  of  such  individuals  is  harsh,  irritating  to  the  healthy 
ear,  the  words  are  badly  enunciated  and  hence  are  difficult,  for  those 
unaccustomed  to  the  peculiarities  of  the  vocabulary  and  accent,  to 
understand. 

Pathology. — Some  of  the  pathologic  findings  in  deaf-mutes  are  as 
follows:  The  nerve-fibers  in  the  modiolus  are  lessened  in  number. 
Ganglionic  cells  in  the  spiral  canal  may  be  few  in  number.  There  may 
be  new  formation  of  bone  in  the  scala  tympani  and  the  lamina  spiralis 
may  be  entirely  wanting.  The  vestibular  and  cochlear  windows  may 
be  filled  with  newly  formed  bone;  ganglionic  cells  may  fail  or,  having 
once  formed,  may  later  atrophy  or  degenerate.  In  the  aqueductus 
cochlae  new  growths  composed  of  bone,  connective  tissue,  or  nerve  tissue 
may  take  place.  Failure  of  development  of  some  of  the  essential  parts 
may  occur  and  the  lamina  spiralis  membranacea  may  be  wanting;  again, 
there  may  be  no  organ  of  Corti  or  spiral  ligament  with  its  stria  vascu- 
laris.  The  organ  of  Corti  may  be  stunted  (flat)  or  the  hair-cells  lacking. 
There  may  be  a  displacement  of  Reisner's  membrane. 

Causation. — Congenital  deaf-mutism  is,  in  the  great  majority  of 
cases,  the  result  of  heredity  or  of  the  intermarriage  of  those  closely 

554 


DEAF-MUTISM 


555 


related,  as,  for  example,  of  first  cousins.  Mr.  Graham  Bell,  in  a  study 
of  2262  congenital  deaf-mutes,  states  that  there  were  deaf-mutes  in  the 
immediate  families  of  more  than  one-half  of  the  near  relatives,  or  of 
1232.  Nevertheless,  direct  transmission  of  this  defect  is  not  so  common, 
for  in  Hartmann's  statistics  it  is  shown  that  of  276  couples,  of  whom  one, 
•either  the  father  or  mother  was  a  deaf-mute,  there  were  born  only  n 
children  who  were  congenitally  deaf,  of  a  total  number  of  419  children. 
When  both  parents  are  deaf-mutes,  Bell  states  that  about  one-third  of 
all  the  children  are  born  deaf. 

Marriage  of  those  of  close  blood  relationship  is,  therefore,  a  frequent 
cause  of  congenital  deaf-mutism.  The  immediate  offspring  resulting 
from  such  marriage  may  be  deaf  or  the  defect  may  not  occur  until  the 
second  or  third  generation.  Statistics  relative  to  deaf-mutism  as  a 
result  of  close  intermarriage  vary,  according  to  different  writers,  from  6 
to  25  per  cent,  of  all  children  born  to  such  parents.  The  number  of 
deaf-mutes  in  proportion  to  a  stated  population  found  in  different  coun- 
tries varies  very  greatly.  Thus,  in  Switzerland  the  number  of  deaf-mutes 
to  each  100,000  population  has  been  as  high  as  245,  whereas  in  Holland, 
the  number  per  100,000  has  been  as  low  as  43.  In  certain  countries  the 
proportion  is,  as  stated  by  Wilde,  as  high  as  i  to  every  206  of  the  popu- 
lation. The  high  rate  in  Switzerland  is  accounted  for  on  the  ground 
that  in  this  country  the  intermarriage  of  those  closely  related  is  a  common 
custom.  Opposed  to  the  theory  that  consanguineous  marriage  is  re- 
sponsible for  the  large  number  of  deaf-mutes  in  Switzerland,  Wishard, 
who  lived  for  eleven  years  in  Persia,  where  he  practised  medicine,  states 
that  he  never  saw  a  case  of  deaf-mutism  there  which  was  due  to  this 
cause,  although  consanguineous  marriages  are  very  common. 

Acquired  deaf-mutism  is  more  frequent  than  the  congenital  variety. 
While  statistics  on  this  point  vary  somewhat,  the  most  reliable  informa- 
tion seems  to  indicate  that  about  twice  as  many  cases  are  acquired  as 
are  congenital.  However,  Hartmann  states  that  of  8404  cases  of  deaf- 
mutism,  66  per  cent,  were  congenital.  Between  the  years  of  1844  and 
1900,  2227  deaf-mutes  were  admitted  to  the  Indiana  Institution  for  the 
Education  of  the  Deaf.  Only  754  of  this  number,  or  less  than  34  per 
cent.,  according  to  the  records,  were  congenitally  deaf.  The  records  of 
deaf  and  dumb  institutions  are  not  entirely  reliable  concerning  this 
point,  for  the  reason  that  the  statements  of  the  parents  concerning  the 
cause  of  the  deafness  are  relied  upon,  whereas  a  most  careful  physical 
examination  of  the  ear  is  necessary  to  determine  whether  or  not  there 
has  been  a  middle-ear  disease  present  which  has  been  a  cause  of  the 
impaired  perception  subsequent  to  the  birth  of  the  child. 


556  THE   PRINCIPLES   AND   PRACTICE   OF  OTOLOGY 

Acquired  deaf-mutism  is  the  result  (a)  of  primary  affections  of  the 
ear  due  to  injuries  or  to  suppurative  otitis  media;  (6)  of  general  dis- 
eases, the  exanthemata,  la  grippe,  typhoid  fever,  mumps,  whooping- 
cough,  and  congenital  syphilis;  (c)  of  inflammatory  affection  of  the 
meninges,  as  cerebrospinal  meningitis  and  simple  meningitis.  Follow- 
ing any  of  the  above-named  general  or  local  diseases  the  deafness 
is  caused  by  an  extension  of  the  inflammatory  or  suppurative  process 
into  the  labyrinth,  either  from  the  meninges,  in  case  of  meningitis,  or 
from  the  tympanic  cavity  when  the  middle  ear  is  the  seat  of  a  violent 
inflammation. 

Diagnosis. — Infants  exhibit  no  evidence  of  the  perception  of  sounds 
before  the  age  of  four  months,  and  hence  it  is  impossible  prior  to  this 
period  to  determine  the  presence  of  deafness.  Practically  speaking, 
the  behavior  of  the  child  seldom  arouses  the  suspicion  of  congenital 
deafness  before  it  arrives  at  the  age  when  it  should  begin  to  speak 
articulate  words.  Hovell  says  that  the  ability  of  a  child  to  repeat  the 
words  "papa"  and  "mamma"  is  no  evidence  that  it  has  ever  heard  these 
words,  for  he  believes  even  very  young  children  learn  to  read  the  lips 
of  parents  who  frequently  repeat  these  words  while  the  infant  is  watching 
the  necessary  mouth  movements.  Even  when  the  child  has  passed  the 
age  when  it  should  be  able  to  begin  speaking,  many  parents  are  apt  to 
assign  some  reason  other  than  deafness  as  a  cause  of  the  backwardness 
in  this  respect.  The  opinion  that  the  child  has  no  defect  of  audition 
is  many  times  firmly  fixed  in  the  minds  of  the  parents  of  the  congen- 
itally  deaf,  for  the  reason  that  they  think  the  infant  perceives  such 
noises  as  are  produced  by  walking  across  the  floor,  slamming  a  door, 
the  falling  of  a  weight,  or  the  passing  of  heavy  wagons  in  the  street. 
The  totally  deaf  soon  acquire  a  most  acute  general  sensibility,  and  the 
above  instances  of  supposed  hearing,  as  stated,  are  really  instances  of 
feeling,  the  jar  of  the  noise-producing  body  causing  some  behavior  on 
the  part  of  the  child  which  is  interpreted  as  effected  by  hearing.  The 
slamming  of  a  door  awakens  the  child  from  its  sleep  or  the  footsteps 
of  the  mother  on  the  floor  attract  the  child  to  turn  around,  but  not 
because  it  hears  the  sound  of  either.  The  statements  of  the  parents 
regarding  the  hearing  of  suspected  deaf  children  are,  therefore,  mis- 
leading, and  hence  some  means  of  examination  of  function  must  be 
chosen  which  the  child  can  neither  see  nor  feel.  A  fairly  satisfactory 
functional  test  may  be  conducted  as  follows:  While  the  child  sits  upon 
the  floor  or  in  the  lap  of  an  attendant  it  should  be  completely  entertained 
in  some  way.  The  examiner  stands  behind  the  child  and  should  not  be 
seen  by  it.  A  series  of  gongs  or  tuning-forks  may  be  used  for  making 


DEAF-MUTISM 


557 


the  test.  It  is  essential  to  ascertain  first  whether  or  not  there  is  total 
absence  of  perception  for  moderately  loud  noises.  For  this  purpose 
the  series  of  Japanese  gongs  are  convenient.  Each  bell  of  the  series 
may  be  struck  with  a  mallet,  while  at  the  same  time  some  competent 
witness  is  noting  the  effect,  if  any,  upon  the  infant's  facial  expression. 
Should  the  child  hear  any  of  the  sounds  thus  produced  a  pleased  and 
intelligent  expression  of  the  face  is  noted,  while  at  the  same  time  it 
will  turn  toward  the  source  of  sound.  Should  it  be  determined  with 
certainty  that  some  degree  of  hearing  is  present,  the  Hartmann  set  of 
tuning-forks  may  then  be  used  and  the  effect,  if  any,  of  the  same  upon 
the  child's  face,  at  the  same  time  be  carefully  noted.  If  these  ex- 
periments are  conducted  in  such  manner  as  to  eliminate  the  possibility 
of  impressions  reaching  the  child  through  either  sight  or  jar,  and 
the  child  shows  no  change  of  countenance  during  the  time,  it  may  be 
reasonably  certain  that  a  high  degree  of  deafness  is  present.  Physical 
evidence  of  congenital  deaf-mutism  may  be  present  in  the  form  of 
atresia  of  the  external  auditory  canals,  but  this  is  rare  as  a  bilateral 
defect. 

The  diagnosis  of  acquired  deafness  may  be  made  by  the  above 
methods,  especially  in  cases  where  the  aural  disease  which  destroyed 
the  hearing  occurs  at  an  age  prior  to  that  at  which  speech  has  been 
acquired.  In  cases  occurring  at  an  age  after  some  degree  of  speech 
had  already  been  acquired,  but  was  subsequently  lost,  the  history  of 
the  case  will  be  helpful,  and  a  physical  examination  of  the  middle  ear, 
in  connection  with  a  functional  examination  by  means  of  tuning-forks, 
will  leave  no  doubt  concerning  the  nature  of  the  defect.  It  should  never 
be  understood  that  total  deafness  is  an  essential  to  deaf-mutism,  for 
such  is  certainly  not  the  case,  since  in  any  individual  who  in  early  life 
hears  the  human  voice  only  when  spoken  loudly  and  near  by  deaf- 
mutism  is  certain  to  develop.  A  large  percentage  of  the  inmates  of 
institutions  for  the  education  of  the  deaf  are  able  to  hear  loud  noises, 
and  sometimes  to  distinguish  words  or  sentences  when  spoken  in  a  loud 
voice  and  close  to  the  ear.  Bezold  found  among  276  deaf-mutes  only 
79  who  were  absolutely  deaf. 

Prognosis. — The  prognosis  as  to  restoration  of  hearing  and  the 
acquirement  of  speech  is  extremely  unfavorable.  Politzer  and  Hartmann 
state  that  cases  of  congenital  deafness  sometimes  improve,  and  the 
former  author  says  that  the  prognosis  is  much  better  in  the  congenital 
than  in  the  acquired  variety.  Occurring  as  the  result  -of  measles, 
scarlet  fever,  diphtheria,  or  cerebrospinal  meningitis  the  prognosis 
is  always  bad,  no  case  of  recovery  having  as  yet  been  recorded. 


558  THE   PRINCIPLES   AND   PRACTICE   OF   OTOLOGY 

Treatment. — When  directed  toward  the  cure  of  the  deafness, 
treatment  of  the  aural  condition  is  usually  hopeless.  On  the  other 
hand,  when  the  treatment  is  given  with  a  view  to  the  improvement  of 
the  child's  health  and  to  the  proper  development  of  its  mental  faculties, 
much  good  can  often  be  accomplished.  If  the  defect  of  speech  and 
hearing  has  resulted  from  some  disease  which  has  left  a  chronic  dis- 
charging ear,  this  should  be  treated  according  to  the  principles  stated 
in  the  chapter  on  Chronic  Otitis  Media  Purulenta.  Much  discussion 
has  arisen  of  late  concerning  the  causative  relation  of  enlarged  tonsils 
and  adenoids  to  deaf-mutism,  and  as  to  the  effect  upon  the  deaf-mutism 
resulting  from  their  complete  removal.  There  can  be  no  question  con- 
cerning the  evil  results  of  these  growths  when  considered  in  the  role  of 
predisposing  factors  in  the  causation  of  aural  suppuration;  and  especially 
is  this  true  when  these  pharyngeal  and  nasopharyngeal  obstructions  are 
present  during  attacks  of  the  exanthemata,  to  which  all  children  are 
liable.  However  influential  may  have  been  the  original  causative 
relation  between  adenoids  and  deaf-mutism,  when  the  latter  is  once 
established  as  a  result  of  the  more  or  less  complete  destruction  of 
the  perceptive  portion  of  the  organ  of  hearing,  it  is  extremely 
doubtful  if  the  subsequent  removal  of  the  tonsils  and  adenoids  has 
ever  improved  the  deaf-mutism  materially  in  any  case.  As  a  pro- 
phylactic measure  and  as  a  means  of  improving  the  physical  and 
mental  condition  of  the  child,  these  growths  should  in  every  case  be 
thoroughly  removed. 

In  children  who  have  suffered  severe  damage  to  both  ears  as  a  result 
of  scarlatina  or  other  like  disease,  but  who  nevertheless  retain  enough 
hearing  to  distinguish  words  spoken  in  a  loud  voice,  it  is  highly  essential 
that  care  be  taken  to  give  frequent  opportunity  to  such  children  to 
hear  spoken  words  and  sentences,  since  otherwise  deaf-mutism  will  be 
rapidly  acquired,  when  it  should  have  been  in  some  measure  at  least 
prevented.  Children  too  deaf  to  be  effectually  educated  in  the  ordinary 
way  in  the  public  schools  must  be  sent,  at  the  age  of  seven  or  eight,  to 
institutions  especially  provided  for  this  unfortunate  class. 

Institutions  for  the  education  of  the  deaf  give  instruction  by  three 
principal  methods:  (i)  Entirely  by  means  of  sign  language;  (2)  by 
the  purely  oral  method,  and  (3)  by  the  combination  of  the  sign  and  oral 
methods.  Each  of  these  plans  has  its  advantages  and  advocates. 
The  sign  method  is  easiest  to  learn,  but  the  deaf-mute  is  subsequently 
at  the  disadvantage  of  being  unable  to  converse  with  the  outside  world 
and  is  put  to  the  constant  necessity  of  communicating  with  those  about 
him  by  means  of  writing.  When  educated  by  the  oral  method  the 


DEAF-MUTISM  559 

individual  is  able  to  converse  with  those  about  him  provided  the  mouth 
of  the  person  with  whom  he  talks  is  visible  and  the  articulation  is  proper. 
Efficient  training  by  this  method  requires  a  period  of  six  or  eight  years 
in  most  children.  The  combination  of  sign  and  oral  methods  gives 
the  obvious  advantage  of  being  able  to  converse  by  either,  but  it  is 
asserted  that  the  child  will  usually  neglect  the  oral  for  the  use  of  the 
manual,  until  finally  he  is  unable  to  use  but  the  one  method  efficiently. 


INDEX 


ABSCESS,  Bezold's,  310 
diagnosis  of,  311 
nature  of,  Fig.  152 
treatment  of,  311 
cerebellar,  after-treatment  of,  461 
diagnosis  of,  457 
symptoms  of,  456 
treatment  of,  457 

perisinous,  in  sinus  thrombosis,  425 
postaural,  Fig.  181 
subperiosteal,  312 
Abstraction     of     blood     in     treatment     of 

furuncle,  125 
Adenoids  as  cause  of  aural  affections,  203 

of  acute  tubotympanic  catarrh,  235 
diagnosis  of,  210 
earache  due  to,  204 
relation  of,  to  deaf-mutism,  558 
treatment  of,  212 
typical  facies  of,  Fig.  117 
Administration  of  drugs,  cause  of  labyrin- 
thine anemia,  525 
Adrenalin  chlorid,  use  of,  in  aural  surgery, 

35i 

use  of,  in  examining  nose,  175 
After-treatment  of  cerebellar  abscess,  461 

operation  for  sinus  thrombosis,  435 
Alcohol-boric  acid  lotion  in  chronic  purulent 

otitis  media,  349 
Allport's  aural  syringe,  342 
Anemia  of  labyrinth,  525 
diagnosis  of,  526 
symptoms  of,  525 
treatment  of,  526 
Anesthesia  in  ossiculectomy,  357 
Anesthetics    for    removal    of    tonsils    and 

adenoids,  213 
danger  from  use  of,  213 
general,  in  incision  of  drum  membrane, 

245 
local,  in  incision  of  drum  membrane,  245 

Angioma  of  auricle,  98 

cavernous,  98 

treatment  of,  99 
Annular  ligament,  38 

36 


Annulus  tympanicus,  23,  45 
Anterior  lacerated  foramen,  24,  29 
Antisepsis,  in  radical  mastoid  operation,  381 
in    treatment    of    acute    catarrhal    otitis 

media,  258 

Antrum  of  mastoid,  21,  26 
Appearance  of  patient  in  brain-abscess,  440 
Aqueductus  cochleae,  33 

vestibuli,  35,  54 
Area  cochlea;,  31 

vestibularis  inferior,  31 

superior,  31 
Artery  forceps,  293 
middle  meningeal,  21 
occipital,  25 
stapedial,  32 
Aspergillus  flavus,  137 

niger,  Fig.  79 
Astringents    in    acute     suppurative    otitis 

media,  276 

Auditory  canal,  anterior  wall  of,  43 
inferior  wall  of,  43 
posterior  wall  of,  43 
superior  wall  of,  41 

meatus,  obstacles  to  examination  of,  175 
Aural  applicator,  341 

bent  at  tip,  343 
auscultation,  190 
curets,  355 
discharge,  cessation  of,  in  chronic  mas- 

toiditis,  372 

in  cerebellar  abscess,  456 
in  infective  meningitis,  462 
discharges,  bacteriology  of,  71 
specula,  169 

long,    for    examination    of    obstructed 

auditory  meatus,  Fig.  99 
of  usual  length,  Fig.  93 
syringe,  341 
Auricle,  39,  60 
absence  of,  87 

of  lobule  of,  85 

affections  of  perichondrium  of,  91 
angioma  of,  98 

cartilaginous  projections  of,  85 
561 


562 


INDEX 


Auricle,  deformity  of,  from  perichondritis,  92 

from  trauma,  Fig.  64 
detachment   of,    for   removal   of   foreign 

body,  146 
of  osteoma,  154 
diseases  of,  84 
epithelioma  of,  102 
functions  of,  64 
malformations  of,  84 
malignant  tumors  of,  100 
othematoma  of,  Fig.  65 
papilloma  of,  98 
perichondritis  of,  91 
relations  to  linea  temporalis,  40 
sarcoma  of,  100 
supernumerary,  89 
tumors  of,  96 
benign,  96 
malignant,  100 
Auscultation  sounds,  191 
Autophonia  in  acute  tubotympanic  catarrh, 
238 

BACON'S  artificial  leech,  Fig.  75 
Bacteria,  how  they  get  into  middle  ear,  70 
Bacteriology  of  aural  discharges,  71 
of  cerebrospinal  meningitis,  74 
of  diphtheria,  73 
of  ear,  69 
of  influenza,  %3 
of  measles,  72 
of  otitis  media,  74 

of  infants,  75 
of  scarlet  fever,  71 

with  diphtheria,  73 
of  typhoid  fever,  74 
Ballance's  method  of  dealing  with  internal 

jugular  vein  in  thrombosis,  432 
report  of  case  in  which  sharp  instrument 

failed  to  enter  abscess  cavity,  450 
use  of  canula  with  rings  in  exploration  of 

cerebellar  abscess,  460 
Bean  in  external  auditory  meatus,  Fig.  81 
Bezold's  abscess,  310 
diagnosis  of,  311 
nature  of,  Fig.  152 
treatment  of,  311 

Black  on  influence  of  climate  on  dry  middle- 
ear  catarrh,  502 
Blake's  middle-ear  syringe,  342 

polypus  snare,  354 

Bloodletting  in  Meniere's  disease,  531 
Boils  of  external  auditory  meatus,  121 


Boric  acid  after  mastoid  operation,  307 
and  alcohol  lotion,  138 
in  otomycosis,  138 
in  brain  surgery,  453 
powder  in  acute  catarrhal  otitis  media, 

261 

Brain,  abscess  of,  436 
acute,  436 
chronic,  438 
contents  of,  451 
drainage  of,  452 

through  tegmen,  447 
dressing  of,  452 
encapsulated,  450,  Fig.  273 
expansion    of    brain    substance    after 

evacuation  of,  452 
exploration  of,  450 
inspection  of  walls  of,  451 
irrigation  of,  451 
location  of,  436 
natural  cure  of,  443 
of  otitic  origin  most  common,  436 
result  of  surgical  treatment  of,  443 
sloughing  tissue  in,  451 
surgical  treatment  of,  445 
symptomless,  442 

CANAL  of  Rosenthal,  55 
Canalis  musculotubarius,  38 
Caries  of  external  osseous  meatus,  157 
cause  of,  157 
diagnosis  of,  157 
treatment  of,  158 
of  sigmoid  sinus  groove,  416 
of  temporal  bone,  366 
Carotid  canal,  35 

ridge,  36 

Carron  oil  in  acute  eczema,  107 
Cartilaginous  spurs,  Fig.  60 
Catarrh  of  middle  ear,  chronic,  475 
Catheter    inflation    in    treatment    of    acute 

tubotympanic  catarrh,  242 
Catheterization  of  Eustachian  tube,  181 
fatal  results  of,  192 
methods  of,  185-188 
obstacles  in,  183 
preparation  for,  182 
technic  of,  185 
Causation  of  acute  catarrhal  otitis  media, 

250 

mastoiditis,  278 
suppurative  otitis  media,  263 
tubotympanic  catarrh,  235 


INDEX 


563 


Causation  of  anemia  of  labyrinth,  525 
of  chronic  mastoiditis,  365 

non-suppurative  otitis  media,  477 

otitis  interna,  537 

purulent  otitis  media,  323 
of  croupous  inflammation,  133 
of  deaf-mutism,  554 
of  diseases  of  the  perceptive  apparatus, 

5i7 

of  eczema,  acute,  104 
of  embolism  of  labyrinth,  532 
of  furuncle,  121 
of  herpes  zoster,  118 
of  hyperemia  of  labyrinth,  527 
of  lupus  vulgaris,  116 
of  mastoiditis  in  infants,  318 
of  Meniere's  disease,  529 
of  otitis  externa  diffusa,  128 
of  otomycosis,  136 
of  secondary  otitis  interna,  534 
Caustics  in  treatment  of  granulations,  351 

of  lupus,  115,  118 

Cerebellar  abscess,  after-treatment  of,  461 
diagnosis  of,  457 
symptoms  of,  456 
treatment  of,  457 

Cerebellum,  exploration  in  abscess  of,  460 
Cerebral  semicircular  canal,  29,  51 

surface  of  petrous  bone,  24,  29 
Cerebrospinal  fluid,  specific  gravity  of,  in 

meningitis,  465 
meningitis     as     cause     of     labyrinthine 

affections,  546 
bacteriology  of,  74 

Cervical  adenitis  in  chronic  mastoiditis,  372 
lymphadenitis,  in  acute  suppurative  otitis 

media,  268 
Cessation  of  aural  discharge  as  symptom  of 

brain-abscess,  441 
Chills  in  brain-abscess,  439 
in  sinus  thrombosis,  418 
Cholesteatoma  of  mastoid,  367 
Chorda  tympani  nerve,  33 

course  of,  through  tympanic  cavity, 

324 
destruction  of,   in   chronic   purulent 

otitis  media,  316 
Climate,    influence   of,    on   dry   middle-ear 

catarrh,  501 

Cocain  in  aural  surgery,  351 
in  examining  the  nose,  176 
Cochlea,  55 

window,  niche  of,  38 


Complications  following  operation  for  brain- 
abscess,  455 

of  middle-ear  inflammation,  75 
Conduction  of  sound  waves,  65 
Constipation  in  sinus  thrombosis,  420 
Convulsions  in  otitic  meningitis,  463 
Corrosions  of  temporal  bone,  27,  28 
Crista  transversa,  31 
Croupous  inflammation  of  external  meatus, 

133 

causation  of,  133 
treatment  of,  133 
Cupping    glass   for    abstraction    of    blood, 

Fig.  76 
Curetage  of  aditus  ad  antrurri,  302 

of  Eustachian  tube  in  chronic  purulent 

otitis  media,  364 
in  radical  mastoid  operation,  392 
of  middle  ear  in  chronic  purulent  otitis 

media,  357 
indications  for,  357 
of  sigmoid  sinus  in  thrombosis,  433 
Curets,  adenoid,  Figs.  124  and  127 
Cutaneous   affections   of  the  external  ear, 
104 

DANGER  to  life  from  chronic  suppurative 

otitis  media,  325 
Deaf-mutism,  554 

acquired,  555 

causation  of,  554 

diagnosis  of,  556 

prognosis  of,  557 

treatment  of,  558 
Deafness,  apoplectiform,  530 

at  birth,  63 

due  to  epidemic  cerebrospinal  meningitis, 

546 
to  impacted  cerumen,  148 

in  chronic  mastoiditis,  372 

in  inflammation  of  labyrinth,  535 

in  labyrinthine  anemia,  525 
hyperemia,  528 

in  Meniere's  disease,  530 
Death  from  removal  of  foreign  body  from 

ear,  141 

Dehiscences,  30 

Delirium  in  otitic  meningitis,  463 
Dench's  results  of  operative   measures  in 
dry  middle-ear  catarrh,  511 

vaporizer,  491 
Depletion    in    treatment    of    labyrinthine 

hyperemia,  529 


564 


INDEX 


De  Vilbiss'  atomizers,  Fig.  103 
bone-forceps,  451 
powder  blower,  347 

Descending  plate  of  squamous  bone,  21 
Diagnosis  of  acute  mastoiditis,  279 
myringitis,  225 
suppurative  otitis  media,  270 
tubotympanic  catarrh,  240 
of  adenoids,  210 
of  brain-abscess,  442 
of  caries  and  necrosis  of  temporal  bone, 

552 

of  cerebellar  abscess,  457 
of  chronic  mastoiditis,  373 

otitis  interna,  538 

purulent  otitis  media,  329 
of  deaf-mutism,  556 
of  diseases  of  labyrinth,  526 

of  perceptive  apparatus,  521 
of  epithelioma,  102 
of   foreign    bodies   in    external    auditory 

meatus,  141 
of  furuncle,  123 
of  hyperemia  of  labyrinth,  528 
of  impacted  cerumen,  148 
of  infectious  meningitis,  464 
of  labyrinthine  syphilis,  541 
of  lupus  erythematosus,  115 

vulgaris,  117 

of  mastoiditis  in  infants,  318 
of  Meniere's  disease,  531 
of  mumps,  548 
of  noma,  113 
of  othematoma,  94 
of  otitis  externa  diffusa,  129 
of  otomycosis,  136 
of  sarcoma,  100 
of  secondary  otitis  interna,  535 
of  sigmoid  sinus  thrombosis,  418 
of  sinus  phlebitis  and  sinus  thrombosis, 

418 

Diagnostic  tube,  Fig.  113 
Differential  diagnosis  of  acute  tubotympanic 
catarrh,  acute  catarrhal  otitis  media, 
and  acute  suppurative  otitis  media, 
277 

of  uncomplicated  intracranial  diseases, 

465 
Digastric  fossa,  25 

groove,  25 
Diphtheria  as  cause  of  acute  suppurative 

otitis  media,  264 
bacteriology  of,  73 


Diphtheritic  inflammation  of  external  audi- 
tory meatus,  134 
causation  of,  134 
treatment  of,  134 
Diplopia  in  brain-abscess,  440 
Diseases   of    labyrinth    due    to    circulatory 

disturbances,  525 
of  perceptive  portion  of  hearing  apparatus, 

Si? 

causation  of,  517 
diagnosis  of,  521 
differential  diagnosis  of,  523 
general  considerations  of,  517 
prognosis  of,  524 
symptoms  of,  519 
Drainage  after  ligation  of  jugular  vein  in 

sinus  thrombosis,  433 
Drum  membrane,  44,  60 

adhesions  of,  in  dry  middle-ear  catarrh, 

483 
appearance     of,     in     dry     middle-ear 

catarrh,  480 
atrophy  of,  484 
calcareous  deposits  in,  481 
color  of,  in  dry  middle-ear  catarrh,  483 
epithelial  layer  of,  46 
fibrous  layer  of,  46 
function  of,  64 
layers  of,  46 
massage  of,  in  chronic  non-suppurative 

otitis  media,  496 
mucous  layer  of,  46 
multiple  incisions  of,  504 
opacity  of,  in  dry  middle-ear  catarrh, 

481 
partial  excision  of,  in  dry  middle-ear 

catarrh,  505 
quadrants,  45 
retraction  of,  in  dry  middle-ear  catarrh, 

481 
Dry  middle-ear  catarrh,  475 

neglect  as  cause  of,  475 
Drying  powders  in  acute  eczema,  107 

in  suppurative  otitis  media,  346 
Duct,  tympanomastoid,  26,  71 
Ductus  endolymphaticus,  54 
Dura  mater,  exposure  of,  in  operations  for 
brain-abscess,  447 

EAR,  bacteriology  of,  69 

diseases,  general  causation  of,  79 
functional  examination  of,  in  dry  middle- 
ear  catarrh,  486 


INDEX 


565 


Ear  hook  for  removal  of  foreign  body,  Fig. 

80 
influence    of    nasal    and    nasopharyngeal 

diseases  upon,  202 
middle,  chronic  catarrh  of,  475 
Eczema,  chronic  form  of,  108 

fissure  of  auditory  meatus  in,  109 
symptoms  of,  109 
treatment  of,  109 
of  auricle  and  external  auditory  meatus, 

104 

acute  form  of,  104 
causation  of,  104 
treatment  of,  104 
Emboli  in  sinus  thrombosis,  420 
Embolism  of  labyrinth,  532 
symptoms  of,  532 
treatment  of,  533' 
Eminentia  arcuata,  29 

pyramidalis,  33 
Endolymph,  57 

Epithelial  layer  of  drum  membrane,  46 
Epithelioma  of  auricle,  102 

affecting  middle  ear  and  labyrinth,  102 
diagnosis  of,  102 
inoperable,  Fig.  70 
treatment  of,  103 
Epitympanum,  42 
Eustachian  bougie,  Fig.  293 

technic  of  introduction,  492 

value    of,   in   chronic   non-suppurative 

otitis  media,  492 
catheter  in  chronic  non-suppurative  otitis 

media,  490 
catheters,  Fig.  106 
tube,  50,  60 

methods  of  determining  patency  of,  175 
catheterization,  181 
Politzer  method,  179 
Valsalva  method,  178 
mucous  membrane  of,  51 
stenosis  of,  in  dry  middle-ear  catarrh, 

485 

Examination  of  function  of  ear,  193 
of  patient,  164 
methods  of,  164 
physical,  164 

Exostoses  of  external  auditory  meatus,  152 
multiple  variety,  Fig.  86 
sessile  variety,  Fig.  87 
small   pedunculated    variety,    Fig. 

86 
External  auditory  canal,  40,  41,  60 


Extradural    brain-abscess,    surgical    treat- 
ment of,  446 

Exudate  in  chronic  non-suppurative  otitis 

media,  476 

removal  of,  in  chronic  non-suppurative 
otitis  media,  494 

Eye,  changes  of,  in  brain-abscess,  440 
disturbance  of,  in  infective  meningitis,  463 
fundus  of,  in  otitic  meningitis,  463 
pupils  of,  in  meningitis,  464 

FACIAL  canal,  31 

spurious  opening  of,  31,  33 
nerve,    union    of,    with    hypoglossal,    in 

facial  paralysis,  406 
results  of,  407 

paralysis  due  to  labyrinth  infection,  551 
following  radical  mastoid  operation,  403 
recovery  from,  405 
surgical  treatment  of,  405 
in  chronic  suppurative  otitis  media,  327 
Fascia  of  parotid  gland,  40 
Fibrocartilaginous  external  auditory  canal, 

40 

Fibroma  of  auricle,  97 
prognosis  of,  97 
treatment  of,  97 

Fibrous  layer  of  drum  membrane,  46 
Finsen  light  in  lupus,  118 
Fistula  in  sigmoid  sinus  thrombosis,  425 
of  auricle,  congenital,  90 
of  external  auditory  meatus,  158 

meatus,  337 

Floor  of  tympanic  cavity,  36 
Foramen,  anterior  lacerated,  24,  29 
mastoid,  singulare,  31 
stylomastoid,  31 

Foreign  bodies,  extractor  for,  Fig.  83 
in  external  auditory  meatus,  139 
diagnosis  of,  141 
injury  to  ear  in  removal  of,  141 
prognosis  of,  142 
symptoms  of,  140 
treatment  of,  143 
removal  of,  by  tenaculum,  Fig.  82 
Fossa,  middle  cranial,  21 

subarcuatus,  34 
Fracture  of  skull,  20 
Frazier's  operation  for  anastomosis  of  facial 

and  hypoglossal  nerves,  407 
Function  of  auricle,  64 
of  drum  membrane,  64 
of  intrinsic  muscles,  66 


566 


INDEX 


Function  of  organ  of  Corti,  67 
of  stapedius  muscle,  63 
of  tensor  tympani  muscle,  63 
Functional     examination     in     labyrinthine 

disease,  521 

Furuncle  knives,  Figs.  77,  78 
of  external  auditory  meatus,  121 
causation  of,  121 
diagnosis  of,  123 
differential  diagnosis  of,  124 
situation  of,  in  meatus,  Fig.  74 
symptoms  of,  122 
treatment  of,  125 

GASSERIAN  ganglion,  17,  29 

Gauze  wick  in  acute  catarrhal  otitis  media, 

259 

in  chronic  suppurative  otitis  media,  348 
method  of  insertion  of,  Fig.  146 
Geniculate  ganglion,  33 
Glaserian  fissure,  24 
Glenoid  fossa,  21 
Glossopharyngeal  nerve,  17 
Glycerin  and  carbolic  acid  solution,  127 

as     an     anesthetic     for     opening 

furuncle    127 
Goldstein's  case  of  spontaneous  hemorrhage 

from  external  auditory  meatus,  160 
Gonococcus,  74 
Granulation  tissue  in   chronic   suppurative 

otitis  media,  322 

Granulations,  treatment  of,  by  caustics,  351 
Greater  superficial  petrosal  nerve,  29 

HAMMOND'S  mastoid  curets,  386 

Hamulus,  57 

Hartmann's  bone  gouge,  Fig.  223 

dressing-forceps,  348 

Hassler's  statistics  of  intracranial  complica- 
tion of  aural  disease,  412 
Headache  in  infective  meningitis,  462 
Head-mirror  for  aural  examination,  Fig.  91 
Hearing,  impairment  of,  in  acute  catarrhal 

otitis  media,  252 

loss  of,  in  dry  middle-ear  catarrh,  479 
perversions  of,  519 

progressive  loss  of,  in  otosclerosis,  513 
tests  for,  193-201 
acoumeter,  196 
Rinn6's,  199 
Schwabach,  198 
tuning  fork,  196 
voice,  195 


Hearing,  test  for,  watch,  194 

Weber's,  199 
Heat  in  the  treatment  of  acute   catarrhal 

otitis  media,  257 
local  application  of,  in  acute  mastoiditis, 

287 

Heated  air  in  suppurative  otitis  media,  345 
Heliotrema,  57 
Helix,  39 

Hemorrhage,  fatal,  resulting  from  necrosis 
of  carotid  artery  and  sigmoid  sinus  in 
acute  suppurative  otitis  media,  271 
from  external  auditory  meatus,  160 
from    injury    to    sigmoid    sinus    during 

operations,  428 
methods  of  controlling,  428 
from  polypi,  174 
labyrinthine,  529 
spontaneous,     from     external     auditory 

meatus,  160 
vicarious,  162 
Heredity  as  cause  of  chronic  non-suppura- 

tive  otitis  media,  477 
Herpes  zoster  of  auricle,  118 
causation  of,  118 
symptoms  of,  1 19 
treatment  of,  119 
Hiatus  aqueductus  vestibuli,  35 

Fallopii,  29 

Hinkel's  report  of  deaths  from  chloroform 
anesthesia  during  removal  of  tonsils  and 
adenoids,  213 
Holmes  (C.  R.)  on    cause    of    intracranial 

diseases,  409 

Hydrogen  peroxid  in  suppurative  otitis,  344 
Hyperemia  of  labyrinth,  526 
causation  of,  527 
diagnosis  of,  528 
prognosis  of,  528 
symptoms  of,  527 
treatment  of,  529 

ICE-BAG  in  acute  mastoiditis,  287 
Ichthyol  in  lupus,  115 
Impacted  cerumen,  147 
diagnosis,  148 
prognosis,  149 
symptoms,  147 
treatment,  149 

Incision  in  treatment  of  furuncle,  127 
of  drum  membrane  after  acute  mastoid 

operation,  307 
in  acute  catarrhal  otitis  media,  258 


INDEX 


Incision    of    drum    membrane    in     acute 

mastoiditis,  286 
suppurative  otitis  media,  273 

extent  of,  274 

of   dura   mater   in   operation  for   brain- 
abscess,  447,  448 
of  membrana  tympani,  secondary,  after 

partial  closure,  261 
Incisura  Rivini,  45 
Incisures  of  Santorini,  40 
Incus,  47 

Infant  temporal  bone,  21,  38 
Infectious  diseases,  cause  of  acute  suppura- 
tive ear  disease,  263 

Inferior  petrosal  sinus,  thrombus  of,  416 
wall  of  external  osseous  auditory  canal, 

43 

Inflammation  of  labyrinth,  534 
Influenza    as    cause   of   acute   suppurative 

otitis  media,  265 
bacteriology  of,  73 

Insects  in  external  auditory  meatus,  139 
Intermarriage  a  cause  of  deaf-mutism,  555 
Internal  administration  of  drugs  in  treat- 
ment of  chronic  non-suppurative  otitis 
media,  499 
auditory  meatus,  31 

Intracranial  complications  of  suppurative 
processes  in  temporal  bone, 
409 

cause  of,  413 
frequency  of,  412 
general  considerations  of,  409 
diseases,  uncomplicated,  differential  diag- 
nosis of,  465 
extension  in  acute  catarrhal  otitis  media, 

255 

Intrinsic  muscles,  function  of,  66 
Introduction,  17 
Irrigation  of  brain-abscess,  451 

objections  to,  454 

Itching  as  symptom  of  chronic  eczema,  109 
treatment  of,  no 

JANSEN'S  bone-forceps,  426 

mastoid  chisels,  385 
Jugular  bulb,  24 

thrombosis  of,  417 
in  children,  421 
fossa,  36 

surface  of  petrous  bone,  24,  35 
vein,  dissection  of,  from  neck,  in  throm- 
bosis, 432 


]  KERNIG'S  sign  in  otitic  meningitis,  464 
Kerrison's  bone-forceps,  389 
Kirstein's  electric  head  lamp,  Fig.  89 
Kbrner    on   relation   of   suppurative   otitis 

media  to  intracranial  disease,  412 
Kuyk  on  method  of  employment  of  silver 

nitrate  in  chronic  purulent  otitis  media, 

35° 

LABYRINTH,  51,  57,  60 
anemia  of,  525 
diseases    of,     dependent    upon    general 

affections,  545 
due    to    suppuration    and    necrosis    of 

temporal  bone,  550 
hyperemia  of,  526 
necrosis  of,   in  acute  suppurative  otitis 

media,  271 
syphilis  of,  541 
Labyrinthine  affections,  cause  of,  517 

due  to  caries  and  necrosis  of  temporal 

bone,  550 
diagnosis  of,  552 
prognosis  of,  552 
symptoms  of,  551 
treatment  of,  553 
complication  of  chronic  non-suppurative 

otitis  media,  501 
hemorrhage,  529 
diagnosis  of,  531 
prognosis  of,  531 
symptoms  of,  530 
treatment  of,  531 
Lactic  acid  in  lupus,  115 
Landmarks,  obliteration  of,  in  dry  middle- 
ear  catarrh,  481 
Laudanum  and  sweet  oil  in  acute  catarrhal 

otitis  media,  257 
Layers  of  drum  membrane,  46 
Leeching  in  acute  suppurative  otitis  media, 

272 

in  furuncle,  125 
Lesser  petrosal  nerve,  29 
Levator  palati  muscle,  50 
Life  insurance,  aural  symptoms  which  make 

applicant  ineligible,  471 

which  do  not  debar  from,  472 

safety  of  risk  subsequent  to  operative 

treatment,  473 
Ligaments  of  ossicles,  48 
Ligation  of  jugular  vein,  429 
Light  in  aural  examinations,  165 
Linea  temporalis,  22,  40 


568 


INDEX 


Lithemia  as  cause  of  eczema,  108 

Lobule,  39 

Lop  ears,  Fig.  59 

Lotions  for  relief  of  itching  in  eczema,  107 

for  softening  hardened  ear  wax,  151 
Lucae's  pressure  probe,  Fig.  295 
Lumbar  puncture  as  aid  to  diagnosis  in 

meningitis,  464 

in  treatment  of  meningitis,  468 
technic  of  performance  of,  469 
Lupus  erythematosus,  114 
diagnosis  of,  115 
symptoms  of,  114 
treatment  of,  115 
of  ear,  114 
vulgaris,  116 

causation  of,  116 
•  diagnosis  of,  117 
of  auricle,  Fig.  72 
prognosis  of,  117 
symptoms  of,  116 
treatment  of,  117 
Lymph  channels,  61 

MACEWEN'S  line,  23 
Macula  cribrosa  inferior,  31 
media,  31 
superior,  31 
Malleus,  47 

Manhattan  Eye  and  Ear  Infirmary,  record 
of,  showing  frequency  of  intracranial 
complication  of  suppurative  aural  disease, 
412 

Massage  of  drum  membrane  in  chronic  non- 
suppurative  otitis  media, 
496 

caution  in  employment  of,  498 
Hommel's  method  of,  499 
Mastoid  antrum,  21,  26 

a  part  of  middle  ear,  365 
Mastoid  cells,  communication  of,  366 
internal  to  digastric  groove,  416 
field,   denuded,   for  operation  for   acute 

mastoiditis,  295 

for  radical  mastoid  operation,  383 
foramina,  25 
fossa,  22 
operation   as  first  step  of  operation  on 

brain-abscess,  445 
change  of  dressing  in,  308 
for  acute  mastoiditis,  288,  290 

ablation  of  mastoid  cells  in,  301 
blood-clot  dressing  in,  304 


Mastoid    operation    for  acute   mastoiditis, 

dangers  of,  314 

entering  mastoid  antrum  in,  298 
good  effects  of,  308 
initial  incision  in,  292 
irrigation  of  wound  in,  302 
landmarks  to  be  observed  in,  296 
length  of  initial  incision  in,  294 
packing  of  wound  in,  302 
preparation  of  patient  for,  290 
removal  of  mastoid  tip  in,  301 
time  required  for  healing  of,  310 
in  infants  and  children,  319 
preliminary    to    operation    for    sinus 

thrombosis,  424 
process,  24,  25,  60 

eburnated,  384 
region,  24 
size  of,  26,  29 

surrounding  sigmoid  sinus,  415 
tenderness   as   symptom   of   acute    mas- 
toiditis, 281 
tubercle,  24 
Mastoiditis,  acute,  278 

as  complication  of  acute  suppurative 

otitis  media,  268 
causation  of,  278 

changes  that  have  taken  place  at  inner 
end  of  auditory  canal,    middle  ear, 
and  drum  membrane  in,  283 
diagnosis  of,  279 
external    manifestations   over    mastoid 

region  in,  280 

physical  condition  of  patient  in,  279 
prognosis  of,  285 
treatment  of,  286 
chronic,  365 

causation  of,  365 
diagnosis  of,  373 
pathology  of,  366 
radical  operation  for,  375 

accidents  and  dangers  of,  401 

indications  for,  379 

method   of  making  skin  flaps  in, 

394 

technic  of,  381 
symptoms  of,  370 
complicating  acute  catarrhal  otitis  media, 

255 

in  infants,  317 
causation  of,  318 
diagnosis  of,  318 
symptoms  of,  318 


INDEX 


Measles  as  cause  of  acute  suppurative  otitis 

media,  264 
bacteriology  of,  72 
Meatus,  internal  auditory,  31 
Medicated  vapors  in  chronic  non-suppura- 

tive  otitis  media,  491,  495 
in  subacute  catarrhal  otitis  media,  262 
Membrana  tympani,  171.     See  Drum  mem- 
brane. 

appearance  of,  in  acute  otitis  media,  253 
suppurative  otitis  media,  269 
tubotympanic  catarrh,  237 
color  of,  172 
diseased,  172 
diseases  of,  223 
extent  of  incisions  of,  248 
folds  of,  172 
incision  of,  244 
injuries  to,  228 
direct,  228 
from  explosions,  230 
from  falls,  Figs.  133,  134 
indirect,  230 

otoscopic  appearances  following,  232 
symptoms,  231 
treatment,  233 
landmarks  of,  Fig.  96 
light-reflex  of,  172 
reparative  powers  of,  248 
retraction  of,  Fig.  136 
rupture  of,  in  acute  otitis  media,  252. 

See  also  Drum  membrane. 
Membranous  ampulla;,  53 
labyrinth,  57 
semicircular  canal,  52 
Meniere's  disease,  529 
Meningitis,    cerebrospinal,     as     cause    of 

labyrinthine  affections,  546 
bacteriology  of,  74 
otitic  infective,  diagnosis  of,  464 
differential  diagnosis  of,  465 
prognosis  of,  466 
symptoms  of,  462 
treatment  of,  466 
Mentality  in  brain-abscess,  441 

in  sinus  thrombosis,  419 
Microtia  of  auricle,  87,  Fig.  62 
Middle  cranial  fossa,  21 
ear,  17 

acute  affections  of,  223 
catarrh,  chronic,  475 
how  bacteria  get  into,  70 
inflammation,  complication  of,  75 


'  Middle  meningeal  artery,  21 
I  Modiolus,  55 

;  Morphin  in  acute  catarrhal  otitis  media,  256 
mastoiditis,  287 
suppurative  otitis  media,  273 
Mucous  layer  of  drum  membrane,  46 
membrane  of  Eustachian  tube,  51 
pockets,  50 
Multiple  incisions  of  drum  membrane,  504 

after-treatment  of,  504 
Mumps  as  cause  of  labyrinthine  affections, 

547 

Muscles,  levator  palati,  50 
stapedius,  38,  48 
tensor  tympani,  48,  51 
Myringitis,  acute,  224 

diagnosis  of,  225 

symptoms  of,  224 

treatment  of,  225 
chronic,  226 

treatment  of,  227 

NASAL  speculum,  Bosworth's,  Fig.  102 

Myles',  Fig.  100 
Nasopharyngeal  diseases  as  cause  of  acute 

suppurative  otitis  media,  266 
Nasopharynx,  treatment  of,  in  tubotympanic 

catarrh,  243 

Necrosis  of  temporal  bone,  366 
Nerve,  glossopharyngeal,  17 

greater  superficial  petrosal,  29 

lesser  petrosal,  29 

saccularis,  58 

Nervous  and  vascular  supply  of  organ  of 
hearing,  60 

system,  disturbances  of,  in  meningitis,  463 
Niche  of  cochlea,  window,  38 
Noma,  112 

cause  of,  113 

of  auricle  in  child,  Fig.  71 
Normal  salt  solution,  formula  for,  150 
Nose,  diseases  of,  indicative  of  syphilis,  542 
Nystagmus  in  chronic  mastoiditis,  372 

OCCIPITAL  artery,  25 
Occipitomastoid  suture,  25 
Occipitopetrosal  synchondrosis,  35 
Odor  in  chronic  aural  discharge,  326 
Office    furniture,    convenient    arrangement 

of,  Fig.  92 

Ointments  in  acute  eczema,  107 
Operation  for  cerebellar  abscess,  technic  of, 
458 


57° 


INDEX 


Operation  for  sinus  thrombosis,  424 
Optic  neuritis  in  brain-abscess,  440 

in  sigmoid  sinus  thrombosis,  417 
Organ    of    Corti,    deficiency    of,    in    deaf- 
mutism,  554 
function  of,  67 
of  hearing,  vascular  and  nervous  supply 

of,  60 

Osseous  auditory  canal,  anterior  wall  of,  43 
labyrinth,  51 
spiral  lamina,  55,  56 
Ossicles,  47 

ligaments  of,  48 
Ossiculectomy  in  chronic   non-suppurative 

otitis  media,  507 
after-treatment  of,  510 
results  of,  510 
technic  of,  507 
purulent  otitis  media,  357 
technic  of,  358 

Osteoma  of  external  auditory  meatus,  152 
diagnosis,  152 
prognosis,  152 
treatment,  152 
Othematoma,  93 
diagnosis  of,  94 
symptoms  of,  93 
treatment  of,  94 

Otitic  brain-abscess,  pathology  of,  436 
prognosis  of,  443 
symptoms  of,  437 
Otitis  externa  circumscripta,  121 
hemorrhagic  external,  159 
diagnosis  of,  159 
symptoms  of,  159 
treatment  of,  159 
interna,  acute  primary,  534 
secondary,  534 
diagnosis  of,  535 
prognosis  of,  536 
treatment  of,  536 
chronic,  537 
media,  acute,  250 

causation  of,  250 

pathology  of,  251 

prognosis  of,  255 

suppurative,  263 

causation,  263 

diagnosis,  270 

pathology,  266 

prognosis,  271 

symptoms,  266 

treatment,  272 


Otitis  media,  acute,  symptoms  of,  251 

treatment  of,  256 
bacteriology  of,  74 
cause  of  labyrinthine  disease,  518 
chronic  non-suppurative,  475,  490 
causation  of,  477 
pathology  of,  476 
prognosis  of,  487 
symptoms  of,  477 
treatment  of,  490 

by  surgical  means,  503 
purulent,  321 
causation  of,  323 
caustics  in  treatment  of,  351 
constitutional  treatment  of,  339 
diagnosis  of,  329 
dry  method  in  treatment  of,  341 
ear  drops  in  treatment  of,  349 
functional  examination  in,  337 
local  medication  of,  340 
nasal    and    nasopharyngeal    treat- 
ment of,  340 
pathology  of,  321 
surgical  treatment  of,  353 

removal  of  carious  ossicles,  357 
of  polypi,  354 
symptoms  of,  325 
of  infants,  bacteriology  cf,  75 
Otoliths  in  external  auditory  meatus,  139 
Otomycosis,  136 
Otosclerosis,  511 
causation  of,  512 
diagnosis  of,  513 
prognosis  of,  514 
symptoms  of,  513,  514 
treatment  of,  515 

PAIN  in  acute  catarrhal  otitis  media,  251 
in  brain-abscess,  438 
in  chronic  mastoiditis,  371 

suppurative  otitis  media,  328 
in  dry  middle-ear  catarrh,  480 
in  infective  meningitis,  462 
in  otosclerosis,  513 
in  sinus  thrombosis,  419 
Papilloma  of  auricle,  treatment  of,  98 
Paracentesis  in  acute  tubotympanic  catarrh, 

244 

knife,  247 

Paralysis  in  brain-abscess,  441 
Parasitic  inflammation  of  auditory  meatus, 

136 
causation  of,  136 


INDEX 


571 


Parasitic  inflammation  of  auditory  meatus, 

diagnosis  of,  136 
treatment  of,  136 
Parietomastoid  suture,  24 
Parotid  gland,  fascia  of,  40 
Partial  excision  of  drum-head,  505 
Pathology  of  acute  suppurative  otitis  media, 

265 

tubotympanic  catarrh,  236 
of  chronic  mastoiditis,  366 

purulent  otitis  media,  321 
of  sinus  phlebitis  and  sinus  thrombosis, 

4i5 

Perforation  of  drum  membrane  below  pos- 
terior fold,  333 
destruction     of     whole     membrana 

tensa,  334 

great  destruction  of,  332 
in  antero-inferior  quadrant,  332 
in  Shrapnell's  membrane,  335 
posterior  to  umbo,  333 
Perichondritis  of  auricle,  91 
symptoms  of,  91 
treatment  of,  91 
Perilymph,  57 
Perilymphatic  space,  52 
Periosteal   elevator   for   reflecting   flaps   in 

mastoid  operation,  294 
for    separation    of    external    auditory 

meatus,  383 

Petrosquamous  suture,  30 
Petrous  bone,  24 

cerebellar  surface  of,  24,  30 
cerebral  surface  of,  24,  29 
jugular  surface  of,  24,  35 
Phenol-glycerin  solution  in  acute  catarrhal 

otitis  media,  256 

Photophobia  in  brain-abscess,  440 
Phototherapy  in  treatment  of  lupus,  118 
Physical  examination  of  ear,   necessary  to 
determine  eligibility  for  life  insurance,  470 
Physiology,  53 
Pilocarpin  in  labyrinthine  disease,  501 

hemorrhage,  532 

Pitt,  autopsies  showing  frequency  of  intra- 
cranial  complications  of  cranial  disease, 
412 

Plexus  tympanicus,  38 
Pneumococcus,  76,  77 
Politzer  inflation  in  treatment  of  acute 

tubotympanic  catarrh,  242 
Politzerization,   method  of,   179 
modified,  Fig.   104 


Polyotia,  Fig.  63 

Polypi,  destruction  of,  by  caustics,  351 
in  chronic  suppurative  otitis  media,  324 
removal  of,  by  curet  or  snare,  354 
Pomeroy    (O.  D.)    on    use    of   syringe   for 
removal  of  ear  wax  and  foreign  bodies,  149 
Position  of  temporal  bone  in  skull,  19 
Postaural  fistula,  330 
Postauricular  swelling  in  acute  mastoiditis, 

280 

in  chronic  mastoiditis,  371 
Posterior  fold,  division  of,  in  dry  middle-ear 

catarrh,  506 
exaggeration  of,  482 
wall  of  auditory  canal,  43 
Preparation    of   patient   for   operation   for 

sinus  thrombosis,  424 

Primary  incision  in  radical  mastoid  opera- 
tion, 382 

otitis  interna,  534 
Processus  cochleariformis,  38 
Prognosis  of  acute  catarrhal  otitis  media, 

255 

eczema,  105 

mastoiditis,  285 

suppurative  otitis  media,  271 

tubotympanic  catarrh,  241 
of  anemia  of  labyrinth,  526 
of  caries  and  necrosis  of  temporal  bone, 

552 

of  chronic  non-suppurative  otitis  media, 
487 

otitis  interna,  539 

purulent  otitis  media,  324 
of  deaf -mutism,  557 
of  diseases  of  perceptive  apparatus,  524 
of  exostoses  of  external  meatus,  152 
of   foreign    bodies   in    external   auditory 

meatus,  142 

of  hyperemia  of  labyrinth,  528 
of  impacted  cerumen,  149 
of  infective  meningitis,  466 
of  labyrinthine  abscess,  443 
of  lupus  vulgaris,  117 
of  Meniere's  disease,  531 
of  mumps,  548 
of  otitis  externa  diffusa,  130 
of  secondary  otitis  interna,  536 
Promontory,  38 
Pulse  in  chronic  mastoiditis,  372 

in  otitic  meningitis,  463 
Pulse-rate  in  brain-abscess,  439 
in  sinus  thrombosis,  419 


572 


INDEX 


Pupil,  changes  of,  in  brain-abscess,  440 
Pynchon's  mouth-gag,  Fig.  122 

QUADRANTS  of  drum  membrane,  45 
Quincke's  method  of  lumbar  puncture,  464 
Quinlan's  adenoid  forceps,  Fig.  123 

RADICAL  mastoid  operation  for  diagnostic 

purposes,  457 

preliminary  to  operation  for  menin- 
gitis, 266 

preparation  of  patient  for,  381 
Randall  (B.  A.)     tabulated     location     by 
quadrants  of   location  of   perforation   in 
drum  membrane  in  1000  cases,  331 
Recessus  ellipticus,  54 

sphericus,  54 
Relation   of   anatomy   of   tympanic   cavity 

to  quadrate  of  drum,  45 
Respiratory  disturbances  due  to  cerebellar 

abscess,  461 

Retraction  of  auricle,  Fig.  94 
Richards'  aural  bougie,  257 
Roof  of  external  auditory  canal,  21 

SACCTTLARIS  nerve,  58 

Sacculus,  58 

Saccus  endolymphaticus,  35,  54 

Sagging  of  posterosuperior  meatal  wall  as 

symptom  of  acute  mastoiditis,  283 
Sarcoma  of  auricle,  100 

affecting  auditory  meatus,  Fig.  68 
diagnosis  of,  100 

facial  paralysis  resulting  from,  101 
treatment  of,  101 
Scarlatina   as   cause   of  acute   suppurative 

ear-disease,  264 
of  labyrinthine  disease,  545 
bacteriology  of,  71 
with  diphtheria,  bacteriology  of,  73 
Sebaceous  cysts,  96 
removal  of,  97 
treatment  of,  96 
Secondary  acute  otitis  interna,  534 

osseous  spiral  lamina,  55 
Semicircular  canal,  cerebellar,  51 
cerebral,  29,  51 
tympanomastoid,  37,  52 
Sexton  on  results  of  operative  measures  in 

dry  middle-ear  catarrh,  511 
Shock  after  acute  mastoid  operation,  307 
ShrapnelPs    membrane,    sagging    of,    from 
exudate,  254 


Shrapnell's  membrane,  sagging   of,  line  of 

incision  in,  Fig.  145 
Siegel's  otoscope,  Fig.  97 
Sigmoid  sinus,  24 

appearance  when  normal,  426 
exploration  of,  with  aspirating  needle, 

426 
injury  of,   during  operation   for   acute 

mastoiditis,  316 
thrombosis,  diagnosis  of,  418 
sulcus,  31 
Sign  language,  education  of  deaf-mutes  by, 

558 

Silver  nitrate,  Kuyk's  method  of  using,  350 
precautions  in  use  of,  350 
solutions  of,  in  chronic  purulent  otitis 

media,  350 
in  chronic  non-suppurative  otitis  media, 

494 

Sinus,  superior  petrosal,  34 
thrombosis,  415 

after-treatment  of  operation  for,  435 
diagnosis  of,  418 
operation  for,  424 
pathology  of,  415 
sigmoid,  diagnosis  of,  418 
symptoms  of,  418 
treatment  of,  424 
tympanic,  38 
Skin  flaps,  Kbrner's,  394 
Panse's,  396 
suturing  of,  397 
grafting  after  radical  mastoid  operation, 

399 
technic  of,  399 

Skull,  fracture  of,  20 

Solutions  for  syringing  in  chronic  suppura- 
tive otitis  media,  340 

Sound  waves,  conduction  of,  65 

Spinal  accessory  nerve,  17 
canal  of  modiolus,  55 

Spine  of  Henle,  22 
of  suprameatus,  22 

Spurious  opening  of  facial  canal,  31,  33 

Squamomastoid  fissure,  22 
suture,  24 

Squamopetrosal  sinus,  21 

Squamous  bone,  descending  plate  of,  21 
portion  of  temporal  bone,  20 

Stacke's  protector,  389 

Stapedial  artery,  32 

Stapedius  muscle,  38,  48 
function  of,  63 


INDEX 


573 


Stapes,  48 

Staphylococcus,  76 
pyogenes  aureus,  121 
cause  of  boils,  121 

Static  equilibrium,  maintenance  of,  520 

Strabismus  in  chronic  mastoiditis,  372 

Streptococcus,  76 

Styloid  process,  24 

Stylomastoid  foramen,  25,  31 

Superior  petrosal  sinus,  34 

thrombosis  of,  416 
wall  of  external  osseous  auditory  canal,  41 

Supramastoid  crest,  21 

Surgical  treatment  of  meningitis,  technic  of, 
467 

Suture,  occipitomastoid,  25 
parietomastoid,  24 
petrosquamous,  30 

Sweating,   occurrence  of,   in   sinus   throm- 
bosis, 419 

Symptoms  of  acute  catarrhal  otitis  media, 

251 

eczema,  105 

myringitis,  224 

suppurative  otitis  media,  266 

tubotympanic  catarrh,  236 
of  anemia  of  labyrinth,  525 
of  atypic  cases  of  sinus  phlebitis  and  sinus 

thrombosis,  420 
of  brain-abscess,  437 
of  caries  and  necrosis  of  temporal  bone, 

55i 

of  cerebellar  abscess,  456 
of  chronic  mastoiditis,  370 

myringitis,  226 

non-suppurative  otitis  media,  478 

otitis  interna,  537 

purulent  otitis  media,  325 
of  diseases  of  perceptive  apparatus,  519 
of  embolism  of  labyrinth,  532 
of  exostoses  of  external  meatus,  152 
of   foreign    bodies   in    external    auditory 

meatus,  139 
of  furuncle,  122 

of  hemorrhagic  external  otitis,  159 
of  herpes  zoster,  119 
of  hyperemia  of  labyrinth,  527 
of  impacted  cerumen,  147 
of  infective  meningitis,  462 
of  injuries  to  membrana  tympani,  231 
of  labyrinthine  syphilis,  541 
of  lupus  erythematosus,  114 

vulgaris,  116 


Symptoms  of  mastoiditis  in  infants,  318 

of  Meniere's  disease,  530 

of  mumps,  548 

of  othematoma,  93 

of  otitis  externa  diffusa,  129 

of  perichondritis,  91 

of  secondary  otitis  interna,  535 

of  sinus  phlebitis  and  sinus  thrombosis, 

418 

thrombosis,  418 

Synchondrosis,  occipitopetrosal,  35 
Syphilis  as  cause  of  labyrinthine  affections, 

545 
of  auditory  meatus,  161 

treatment  of,  162 
of  concha  and  tragus,  Fig.  88 
of  labyrinth,  541 

diagnosis  of,  541 
Syringing  ear,  method  of,  in  treatment  of 

acute  catarrhal  otitis  media,  260 
in  chronic  suppurative  otitis  media,  340 
frequency  of,  341 

TECHNIC  of  tenotomy  of  tensor  tympani 

muscle,  507 
Teeth,  examination  of,  177 

Hutchinson's,  542 
Tegmen  antri,  necrosis  of,  exposing  dura 

mater,  387 

removal    of,    in    operation    for    brain- 
abscess,  446 
tympani  and  antri,  29 

thickness  of,   compared  with  mastoid 

cortex,  409 

Temperature  after  mastoid  operation,  307 
in  acute  mastoiditis,  280 
otitis  media,  252 
suppurative  otitis  media,  266 
in  brain-abscess,  439 
in  chronic  mastoiditis,  372 
in  otitic  meningitis,  463 
in  sinus  thrombosis,  418 
Temporal  bone,  corrosions  of,  27,  28 
position  of,  in  skull,  19 
squamous  portion  of,  20 
suppuration  and  necrosis  of,  in  relation 

to  life  insurance,  470 
Temporosphenoidal  brain-abscess,  surgical 

treatment  of,  447 
Tensor  palati  muscle,  48,  51 

tympani    muscle,    division    of,    in    dry 

middle-ear  catarrh,  506 
muscle  function  of,  63 


574 


INDEX 


Thrombosis  of  sigmoid  sinus,  diagnosis  of, 

418 

in  acute  mastoiditis,  286 
sinus,  after-treatment  of  operation  for,  435 
Tinnitus    aurium    as    symptom    of    acute 

tubotympanic  catarrh,  236 
due  to  impacted  cerumen,  148 
in    chronic    suppurative   otitis   media, 
_    328 

in  dry  middle-ear  catarrh,  478 
in  otosclerosis,  513 
treatment  of,  500 
Tonsils,  207 

removal  of,  219 

Tractus  spiralis  foraminosus,  31 
Traumatic  hemorrhage  from  auditory  canal, 

162 
Traumatism  as  cause  of  internal  ear  disease, 

5i8 

Treatment  of  ;  cute  catarrhal  otitis  media, 
256 

eczema,  106 

mastoiditis,  286 

myringitis,  225 

suppurative  otitis  media,  272 

tubotympanic  catarrh,  242 
of  adenoids,  212 
of  anemia  of  labyrinth,  526 
of  angioma,  99 
of  aural  deformities,  85 
of  brain-abscess,  445 
of  caries  and  necrosis  of  temporal  bone, 

553 

of  external  osseous  meatus,  158 
of  cartilaginous  projections,  87 
of  cerebellar  abscess,  457 
of  chronic  eczema,  109 
mastoiditis,  375 

accidents  and  dangers  that  may  occur 

or  follow  mastoid  operation,  401 
facial  paralysis  in,  403 
indications  for  radical  operation,  379 
method  of  making  Kbrner  flap,  394 

Panse  flap,  396 
preliminary  remarks,  375 
surgery  of  facial  nerve  in,  405 
technic  of  radical  mastoid  operation, 

38i 

of  skin  grafting,  399 
myringitis,  227 

non-suppurative  otitis  media  by  medici- 
nal means,  490 
by  surgical  means,  503 


Treatment  of  chronic  purulent  otitis  media, 

339.  353 

caustics,  351 

cocain  anesthesia,  351 

constitutional,  339 

ear  drops,  349 

intratympanic  surgery,  354 

local  medication,  340 

mechanical  removal  of  accumu- 
lated septic  matter,  344 

methods  of  drying  the  parts,  345 

nasal  and   nasopharyngeal,    340 

ossiculectomy   and   curetage   of 
middle  ear  and  attic,  357 

removal  of  polypi,  354 
of  congenital  fistula,  90 
of  croupous  inflammation,  133 
of  deaf-mutism,  558 
of  deafness  following  mumps,  548 
of  diphtheritic  inflammation,  134 
of  eczema,  acute,  106 

chronic,  109 

of  embolism  of  labyrinth,  533 
of  epidemic  cerebrospinal  meningitis,  546 
of  epithelioma,  103 
of  exostoses  of  external  meatus,  153 
of  fibroma,  97 
of   foreign    bodies   in   external    auditory 

meatus,  143 
of  furuncle,  125 

of  hemorrhagic  external  otitis,  159 
of  herpes  zoster,  119 
of  hyperemia  of  labyrinth,  528 
of  impacted  cerumen,  149 
of  infective  meningitis,  466 
of  inflammation  of  labyrinth,  536 
of  injuries  to  membrana  tympani,  233 
of  labyrinthine  syphilis,  543 
of  lupus  erythematosus,  115 

vulgaris,  117 

of  mastoiditis  in  children,  310 
of  Meniere's  disease,  531 
of  microtia,  88 
of  othematoma,  94 
of  otitis  externa  diffusa,  130 
of  otomycosis,  137 
of  papilloma,  98 
of  perichondritis,  91 
of  polyotia,  Sg 
of  sarcoma,  101 
of  sebaceous  cysts,  96 
of  sinus  infection  and  sinus  thrombosis 
424 


INDEX 


575 


Treatment    of    sinus    infection    and   sinus 
thrombosis,  technic  of   ligation  of   in- 
ternal jugular  vein  in,  429 
of  supernumerary  auricles,  89 
of  syphilis  of  auditory  meatus,  162 
of  undeveloped  helix,  absence  of  lobule, 

and  cartilaginous  projections,  85 
Trephining  for  cerebellar  abscess,  459 
in  operation  for  temporosphenoidal  brain- 
abscess,  447,  449 
Trismus  in  otitic  meningitis,  463 
Tuberculosis   as   cause   of   suppuration   of 

middle  ear,  268 

Tubotympanic  catarrh,  acute,  235 
diagnosis  of,  240 
pathology  of,  236 
prognosis  of,  241 
symptoms  of,  236 
treatment  of,  242 
Tumors  of  auricle,  96 
benign,  96 
malignant,  100 
Tympanic  bone,  23 

vaginal  portion  of,  24 
cavity,  60 

exudate  in,  Figs.  137,  138,  139 
floor  of,  36 
nerve,  29 
ring,  41 
sinus,  38 
space,  17 
sulcus,  24 

surface  of  petrous  bone,  24 
Tympanomastoid  duct,  21,  26 
fissure,  24 

semicircular  canal,  37,  52 
surface  of  petrous  bone,  37 


Typhoid  fever    as    cause    of    affections    of 

labyrinth,  545 
bacteriology  of,  74 

UTRICULUS  nerve,  57,  58 

VAGUS  nerve,  17 

Vail   (D.  T.)   case  of  herpes  zoster  auris, 

Fig-  73 
Vascular  and  nervous  supply  of  organ  of 

hearing,  60 

Vena  aqueductus  cochleae,  33 
Vertigo  from  increased  labyrinthine  pres- 
sure, 520 

from  syringing  ear,  342 

in  chronic  mastoiditis,  372 
suppurative  otitis  media,  328 

in  dry  middle-ear  catarrh,  480 

in  sinus  thrombosis,  420 
Vestibule,  53 

Vicarious  hemorrhage  of  ears,  162 
Vomiting  in  brain-abscess,  438 

in  meningitis,  464 

in  sinus  thrombosis,  420 

WHEELOCK  (K.  K.)  case  of  spontaneous 
hemorrhage  from  external  auditory  mea- 
tus, 1 60 

Whiting's  encephaloscopes,  451 

X-RAYS  in  treatment  of  lupus,  118 

ZINC  sulphate    in    chronic    purulent    otitis 

media,  351 
Zygoma,  22 
Zygomatic  cells,  28,  29 


SAUNDERS-    ROOKS    ON 


A  Text-Book  of  Legal  Medicine  and  Toxicology.  Edited  by 
FREDERICK  PETERSON,  M.  D.,  Professor  of  Psychiatry  in  the  College 
of  Physicians  and  Surgeons,  New  York;  and  WALTER  S.  HAINES, 
M.  D.,  Professor  of  Chemistry,  Pharmacy,  and  Toxicology,  Rush 
Medical  College,  in  affiliation  with  the  University  of  Chicago.  Two 
imperial  octavo  volumes  of  about  750  pages  each,  fully  illustrated. 
Per  volume:  Cloth,  $5.00  net;  Sheep  or  Half  Morocco,  $6.50  net. 
Sold  by  Subscription, 

IN  TWO   VOLUMES— BOTH  VOLUMES  NOW   READY 

The  object  of  the  present  work  is  to  give  to  the  medical  and  legal  professions 
a  comprehensive  survey  of  forensic  medicine  and  toxicology  in  moderate  compass. 
This,  it  is  believed,  has  not  been  done  in  any  other  recent  work  in  English.  Under 
"  Expert  Evidence  "  not  only  is  advice  given  to  medical  experts,  but  suggestions 
are  also  made  to  attorneys  as  to  the  best  methods  of  obtaining  the  desired  infoi- 
mation  from  the  witness.  An  interesting  and  important  chapter  is  that  on  ' '  The 
Destruction  and  Attempted  Destruction  of  the  Human  Body  by  Fire  and  Chemi- 
cals. ' '  A  chapter  not  usually  found  in  works  on  legal  medicine  is  that  on  ' '  The 
Medicolegal  Relations  of  the  X-Rays. "  This  section  will  be  found  of  unusual  im- 
portance. The  responsibility  of  pharmacists  in  the  compounding  of  prescriptions, 
in  the  selling  of  poisons,  in  substituting  drugs  other  than  those  prescribed,  etc., 
furnishes  a  chapter  of  the  greatest  interest  to  every  one  concerned  with  questions 
of  medical  jurisprudence.  Also  included  in  the  work  is  the  enumeration  of  the 
laws  of  the  various  states  relating  to  the  commitment  and  retention  of  the  insane. 


OPINIONS  OF  THE  MEDICAL  PRESS 


Medical  News,  New  York 

"  It  not  only  fills  a  need  from  the  standpoint  of  timeliness,  but  it  also  sets  a  standard  of 
what  a  text-book  on  Legal  Medicine  and  Toxicology  should  be." 

Columbia  Law  Review 

"  For  practitioners  in  criminal  law  and  for  those  in  medicine  who  are  called  upon  to  give 
court  testimony  in  all  its  various  forms  ...  it  is  extremely  valuable." 

Pennsylvania  Medical  Journal 

"  If  the  excellence  of  this  volume  is  equaled  by  the  second,  the  work  will  easily  take  rank 
as  the  standard  text-book  on  Legal  Medicine  and  Toxicology." 


NERVOUS  AND   MENTAL    DISEASES. 


Church  and  Peterson's 
Nervous  anb  Mental  Diseases 


Nervous  and  Mental  Diseases.  By  ARCHIBALD  CHURCH,  M.  D., 
Professor  of  Nervous  and  Mental  Diseases  and  Medical  Jurisprudence, 
Northwestern  University  Medical  School,  Chicago;  and  FREDERICK 
PETERSON,  M.  D.,  President  New  York  State  Commission  on  Lunacy ; 
Professor  of  Psychiatry  at  the  College  of  Physicians  and  Surgeons, 
N.  Y.  Handsome  octavo,  937  pages  ;  341  illustrations.  Cloth,  $5.00 
net ;  Sheep  or  Half  Morocco,  $6.50  net. 

JUST   ISSUED-NEW   (5th)   EDITION 

This  work  has  met  with  a  most  favorable  reception  from  the  profession  at 
large.  It  fills  a  distinct  want  in  medical  literature,  and  is  unique  in  that  it 
furnishes  in  one  volume  practical  treatises  on  the  two  great  subjects  of  neurology 
and  psychiatry.  In  preparing  this  edition  Dr.  Church  has  carefully  revised  his 
entire  section,  placing  it  in  accord  with  the  most  recent  psychiatric  advances. 
In  Dr.  Peterson's  section  —  Mental  Diseases  —  the  Kraepelin  classification  of 
insanity  has  been  added  to  the  chapter  on  classifications  for  purposes  of  reference, 
and  new  chapters  on  Manio-Depressive  Insanity  and  on  Dementia  Praecox  in- 
cluded. While  the  changes  throughout  have  been  many,  they  have  been  so 
made  as  but  slightly  to  increase  the  size  of  the  work. 


OPINIONS  OF  THE   MEDICAL  PRESS 


American  Journal  of  the  Medical  Sciences 

"  This  edition  has  been  revised,  new  illustrations  added,  and  some  new  matter,  and  really 
is  two  books.  .  .  .  The  descriptions  of  disease  are  clear,  directions  as  to  treatment  definite, 
and  disputed  matters  and  theories  are  omitted.  Altogether  it  is  a  most  useful  text-book." 

Journal  of  Nervous  and  Mental  Dbeases 

"  The  best  text-book  exposition  of  this  subject  of  our  day  for  the  busy  practitioner.  .  .  . 
The  chapter  on  idiocy  and  imbecility  is  undoubtedly  the  best  that  has  been  given  us  in  any 
work  of  recent  date  upon  mental  diseases.  The  photographic  illustrations  of  this  part  of  Dr. 
Peterson's  work  leave  nothing  to  be  desired." 

New  York  Medical  Journal 

"  To  be   clear,  brief,  and  thorough,  and  at  the  same  time  authoritative,  are  merits  that 
ensure  popularity.     The  medical  student  and  practitioner  will  find  in  this  volume  a  ready  and 
resource." 


SAUNDERS'    BOOKS    ON 


Frtihwald  and  WestcottV 
Diseases    of  Children 


Diseases  of  Children.  A  Practical  Reference  Book  for  Students 
and  Practitioners.  By  PROFESSOR  DR.  FERDINAND  FRUHWALD,  of 
Vienna.  Edited,  with  additions,  by  THOMPSON  S.  WESTCOTT,  M.  D., 
Associate  in  Diseases  of  Children,  University  of  Pennsylvania.  Octavo 
volume  of  533  pages,  containing  176  illustrations.  Cloth,  $4.50  net. 

RECENTLY  ISSUED 

This  work  represents  the  author's  twenty  years'  experience,  and  is  intended 
as  a  practical  reference  work  for  the  student  and  practitioner.  With  this  refer- 
ence feature  in  view,  the  individual  diseases  have  been  arranged  alphabetically. 
The  prophylactic,  therapeutic,  and  dietetic  treatments  are  elaborately  discussed. 
The  practical  value  of  the  book  has  been  considerably  enhanced  by  the  many 
excellent  illustrations. 
E.  H.  Hartley,  M.  D., 

Professor  of  Pediatrics,  Chemistry,  and  Toxicology,  Long  Island  College  Hospital,  New  York. 
"It  is  a  new  idea,  which  ought  to  become  popular  because  of  the  alphabetic  arrangement. 
Its  title  expresses  just  what  it  is — a  ready  reference  hand-book." 


RuhrahV 
Diseases  of  Children 


A  Manual  of  Diseases  of  Children.  By  JOHN  RUHRAH,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  College  of  Physicians  and 
Surgeons,  Baltimore.  I2mo  of  404  pages,  fully  illustrated.  Flexible 

leather,  $2.00  net. 

RECENTLY  ISSUED 

In  writing  this  manual  Dr.  Ruhrah's  aim  was  to  present  a  work  that  would  be 
of  the  greatest  value  to  students.  All  the  important  facts  are  given  concisely  and 
explicitly,  the  therapeutics  of  infancy  and  childhood  being  outlined  very  care- 
fully and  clearly.  There  are  also  directions  for  dosage  and  prescribing,  and  a 
number  of  useful  prescriptions  are  included.  The  feeding  of  infants  is  given  in 
detail,  and  the  entire  work  is  amply  illustrated  with  practical  illustrations.  A 
valuable  aid  consists  in  the  many  references  to  pediatric  literature,  so  selected 
as  to  be  easily  accessible  by  the  student. 


INSANITY  AND   HYGIENE. 


A  Practical  Manual  of  Insanity.  For  the  Student  and  General 
Practitioner.  By  DANIEL  R.  BROWER,  A.M.,  M.D.,  LL.  D.,  Professor 
of  Nervous  and  Mental  Diseases  in  Rush  Medical  College,  in  affiliation 
with  the  University  of  Chicago  ;  and  HENRY  M.  BANNISTER,  A.  M., 
M.  D.,  formerly  Senior  Assistant  Physician,  Illinois  Eastern  Hospital 
for  the  Insane.  Handsome  octavo  of  426  pages,  with  a  number  of 
full-page  inserts.  Cloth,  $3.00  net. 

FOR  STUDENT  AND  PRACTITIONER 

This  work,  intended  for  the  student  and  general  practitioner,  is  an  intelligible, 
up-to-date  exposition  of  the  leading  facts  of  psychiatry,  and  will  be  found  of  in- 
valuable service,  especially  to  the  busy  practitioner  unable  to  yield  the  time  for  a 
more  exhaustive  study.  The  work  has  been  rendered  more  practical  by  omitting 
elaborate  case  records  and  pathologic  details,  as  well  as  discussions  of  speculative 
and  controversial  questions. 

American  Medicine 

"  Commends  itself  for  lucid  expression  in  clear-cut  English,  so  essential  to  the  student  in 
any  department  of  medicine.  .  .  .  Treatment  is  one  of  the  best  features  of  the  book,  and  for 
this  aspect  is  especially  commended  to  general  practitioners." 

Bergey's  Hygiene 

The  Principles  of  Hygiene:  A  Practical  Manual  for  Students, 
Physicians,  and  Health  Officers.  By  D.  H.  BERGEY,  A.  M.,  M.  D., 
Assistant  Professor  of  Bacteriology  in  the  University  of  Pennsylvania. 
Octavo  volume  of  536  pages,  illustrated.  Cloth,  $3.00  net. 

RECENTLY  ISSUED— SECOND  REVISED  EDITION 

This  book  is  intended  to  meet  the  needs  of  students  of  medicine  in  the 
acquirement  of  a  knowledge  of  those  principles  upon  which  modern  hygienic 
practises  are  based,  and  to  aid  physicians  and  health  officers  in  familiarizing 
themselves  with  the  advances  made  in  hygiene  and  sanitation  in  recent  years. 
This  new  second  edition  has  been  very  carefully  revised,  and  much  new  matter 
added,  so  as  to  include  the  most  recent  advancements. 

Buffalo  Medical  Journal 

"  It  will  be  found  of  value  to  the  practitioner  of  medicine  and  the  practical  sanitarian  ;  and 
students  of  architecture,  who  need  to  consider  problems  of  heating,  lighting,  ventilation,  water 
supply,  and  sewage  disposal,  may  consult  it  with  profit." 


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GET  Jk  •  THE  NEW 

THE  BEST  j\  HI  6  T  1  C  &  n  STANDARD 

Illustrated   Dictionary 

Just  Issued-The  New  (4th)  Edition 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry,  and  kindred  branches  ;  with  over  100  new  and 
elaborate  tables  and  many  handsome  illustrations.  By  W.  A.  NEWMAN 
BORLAND,  M.  D.,  Editor  of  "  The  American  Pocket  Medical  Diction- 
ary." Large  octavo,  nearly  800  pages,  bound  in  full  flexible  leather. 
Price,  $4.50  net;  with  thumb  index,  $5.00  net. 

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The  immediate  success  of  this  work  is  due  to  the  special  features  that  distin- 
guish it  from  other  books  of  its  kind.  It  gives  a  maximum  of  matter  in  a  mini- 
mum space  and  at  the  lowest  possible  cost.  Though  it  is  practically  unabridged, 
yet  by  the  use  of  thin  bible  paper  and  flexible  morocco  binding  it  is  only  i  ^ 
inches  thick.  The  result  is  a  truly  luxurious  specimen  of  book-making.  In  this 
new  edition  the  book  has  been  thoroughly  revised,  and  upward  of  two  thousand 
new  terms  that  have  appeared  in  recent  medical  literature  have  been  added,  thus 
bringing  the  book  absolutely  up  to  date.  The  book  contains  hundreds  of  terms 
not  to  be  found  in  any  other  dictionary,  over  100  original  tables,  and  many  hand- 
some illustrations,  a  number  in  colors. 


PERSONAL    OPINIONS 


Howard  A.  Kelly,  M.  D.. 

Professor  of  Gynecology,  Johns  Hopkins  University,  Baltimore. 

"  Dr.  Dorland's  dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  convenient 
site.     No  errors  have  be«n  found  in  my  use  of  it." 

J.  Collins  Warren,  M.D..  LL.D..  F.R.C.S.  (Hon.) 

Professor  of  Surgery,  Harvard  Medical  School. 

"  I  regard  it  as  a  valuable  aid  to  my  medical  literary  work.     It  is  very  complete  and  of 
convenient  size  to  handle  comfortably.     I  use  it  in  preference  to  any  other." 


DISEASES  OF  CHILDREN. 


Diagnostics  of  the  Diseases  of  Children.  By  LEGRAND  KERR, 
M.  D.,  Professor  of  Diseases  of  Children,  Brooklyn  Postgraduate  Med- 
ical School,  Brooklyn.  Octavo  of  550  pages,  fully  illustrated.  Cloth, 
$$.OO  net  ;  Half  Morocco,  $6.50  net. 

JUST  READY—  FOR  THE  PRACTITIONER 

Dr.  Kerr's  work  differs  from  all  others  on  the  diagnosis  of  diseases  of  children 
in  that  the  objective  symptoms  are  particularly  emphasized.  The  author  believes 
that  as  the  objective  symptoms  are  the  main  sources  of  information  in  diagnosing 
children's  diseases,  the  subject  should  be  discussed  with  these  symptoms  as  the 
foundation.  The  constant  aim  throughout  has  been  to  render  a  correct  diagnosis 
as  early  in  the  course  of  the  disease  as  possible,  and  for  this  reason  differential 
diagnosis  is  presented  from  the  very  earliest  symptoms.  The  sequelae  of  the 
various  diseases  have  been  considered  only  to  the  extent  that  they  may  be  of  value 
in  anticipating  them  and  thus  aiding  in  their  early  diagnosis.  The  physician  will 
find  the  many  original  illustrations  a  source  of  much  information  and  help. 


Treatment  of  the  Diseases  of  Children.  By  CHARLES  GILMORE 
KERLEY,  M.  D.,  Professor  of  Diseases  of  Children,  New  York  Polyclinic 
School  and  Hospital.  Octavo  of  550  pages,  illustrated. 

JUST   ISSUED 

This  work  has  been  prepared  for  the  physician  engaged  in  general  practice. 
The  author  presents  all  the  modern  methods  of  management  and  treatment  in 
greater  detail  than  any  other  work  on  the  subject  heretofore  published.  The 
methods  suggested  are  the  results  of  actual  personal  experience,  extending  over  a 
number  of  years  of  hospital  and  private  practice.  Every  method,  therefore,  has 
been  thoroughly  tried  and  its  value  as  a  therapeutic  measure  proved.  Special 
endeavor  has  been  taken  to  have  the  illustrations  of  a  practical  nature. 


SAUNDERS'  BOOKS   ON 


Draper's  Legal  Medicine 

A  Text-Book  of  Legal  Medicine.  By  FRANK  WINTHROP  DRAPER, 
A.  M.,  M.  D.,  Professor  of  Legal  Medicine  in  Harvard  University,  Bos- 
ton ;  Medical  Examiner  of  the  County  of  Suffolk,  Massachusetts,  etc. 
Handsome  octavo  volume  of  573  pages,  fully  illus.  Cloth,  $4.00  net. 

A  NEW  WORK— RECENTLY  ISSUED 

The  subject  of  Legal  Medicine  is  one  of  great  importance,  especially  to  the 
general  practitioner,  for  it  is  to  him  that  calls  to  attend  cases  which  may  prove  to 
be  medicolegal  in  character  most  frequently  come.  The  medicolegal  field  includes 
not  only  deaths  of  a  homicidal  nature,  but  also  suits  at  law — the  fatal  railway  acci- 
dent, machinery  casualties,  and  the  like,  to  which  the  neighboring  physician  may 
be  called,  and  later,  perhaps,  summoned  to  court.  It  is  evident,  therefore,  that 
every  practitioner  should  be  thoroughly  versed  in  all  branches  of  medicolegal 
science.  This  volume,  although  prepared  as  a  help  to  medical  students,  will  be 
found  no  less  valuable  and  instructive  to  practitioners.  The  author  has  had 
twenty-six  years'  experience  as  Medical  Examiner  for  the  city  of  Boston,  his  in- 
vestigations comprising  nearly  eight  thousand  deaths  under  a  suspicion  of  violence. 

Hon.  Olin  Bryan,  LL.  B. 

Professor  of  Medical  Jurisprudence,    Baltimore  Medical  College 

"  A  careful  reading  of  Draper's  Legal  Medicine  convinces  me  of  the  excellent  character  of 
the  work.  It  is  comprehensive,  thorough,  and  must,  of  a.  necessity,  prove  a  splendid  acquisition 
to  the  libraries  of  those  who  are  interested  in  medical  jurisprudence." 

Jakob  and  FisherV 

Nervous  System  and  its  Diseases 

Atlas  and  Epitome  of   the  Nervous   System   and  Its  Diseases. 

By  PROFESSOR  DR.  CHR.  JAKOB,  of  Erlangen.  From  the  Second  Revised 
German  Edition.  Edited,  with  additions,  by  EDWARD  D.  FISHER,  M.  D., 
Professor  of  Diseases  of  the  Nervous  System,  University  and  Bellevue 
Hospital  Medical  College,  New  York.  With  83  plates  and  copious  text. 
Cloth,  $3.50  net.  In  Saunders1  Hand-Atlas  Series. 

The  matter  is  divided  into  Anatomy,  Pathology,  and  Description  of  Diseases 
of  the  Nervous  System.  The  plates  illustrate  these  divisions  most  completely  ; 
especially  is  this  so  in  regard  to  pathology.  The  exact  site  and  character  of  the 
lemon  are  portrayed  in  such  a  way  that  they  cannot  fail  to  impress  themselves  on 
the  memory  of  the  reader. 

Philadelphia  Medical  Journal 

"  We  know  of  no  one  work  of  anything  like  equal  size  which  covers  this  important  and 
complicated  field  with  the  clearness  and  scientific  fidelity  of  this  hand-atlas." 


NURSING. 


De  Lee's  Obstetrics  for  Nurses 

Obstetrics  for  Nurses.  By  JOSEPH  B.  DELEE,  M.D.,  Professor 
of  Obstetrics  in  the  Northwestern  University  Medical  School;  Lecturer 
in  the  Nurses'  Training  Schools  of  Mercy,  Wesley,  Provident,  Cook 
County,  and  Chicago  Lying-in  Hospitals.  I2mo  volume  of  460  pages, 
fully  illustrated.  Cloth,  $2.50  net. 

JUST  ISSUED— NEW  2nd ) EDITION 

The  illustrations  in  Dr.  De  Lee's  work  are  nearly  all  original,  and  represent 
photographs  taken  from  actual  scenes.  The  text  is  the  result  of  the  author's  eight 
years'  experience  in  lecturing  to  the  nurses  of  five  different  training  schools. 

J.  Clifton  Edgar.  M.  D., 

Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  Medical  School,  N.  Y. 
"  It  is  far-and-away  the  best  that  has  come  to  my  notice,  and  I  shall  take  great  pleasure  in 
recommending  it  to  my  nurses,  and  students  as  well." 

Davis*  Obstetric  and 

Gynecologic  Nursing 

Obstetric  and  Gynecologic  Nursing.  By  EDWARD  P.  DAVIS,  A.M., 
M.  D.,  Professor  of  Obstetrics,  Jefferson  Medical  College  and  Philadel- 
phia Polyclinic.  I2mo  of  400  pages,  illustrated.  Buckram,  $1.75  net. 

RECENTLY  ISSUED— SECOND  REVISED  EDITION 

The  Lancet,  London 

"  Not  only  nurses,  but  even  newly  qualified  medical  men,  would  learn  a  great  deal  by  a 
perusal  of  this  book.  It  is  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  can  recom- 
mend." 

Reference   Handbook  for  Nurses 

A  Reference  Handbook  for  Nurses.  By  AMANDA  K.  BECK,  of 
Chicago,  111.  32mo  of  177  pages.  Flexible  leather,  $1.25  net. 

RECENTLY  ISSUED 

This  little  book  contains  information  upon  every  question  that  comes  to  a 
nurse  in  her  daily  work,  and  embraces  all  the  information  that  she  requires  to 
carry  out  any  directions  given  by  the  physician. 

Boston  Medical  and  Surgical  Journal 

"Must  be  regarded  as  an  extremely  useful  book,  not  only  for  nurses,  but  for  physicians." 


io  SAUNDERS'    BOOKS   ON 

Hofmann  and  Peterson's 
Legal  Medicine 

Atlas  of  Legal  Medicine.  By  DR.  E.  VON  HOFMANN,  of  Vienna, 
Edited  by  FREDERICK  PETERSON,  M.  D.,  Professor  of  Psychiatry 
in  the  College  of  Physicians  and  Surgeons,  New  York.  With  120 
colored  figures  on  56  plates  and  193  half-tone  illustrations.  Cloth, 
#3.50  net.  In  Saunders'  Hand-Atlas  Series. 

By  reason  of  the  wealth  of  illustrations  and  the  fidelity  of  the  colored  plates, 
the  book  supplements  all  the  text-books  on  the  subject.  Moreover,  it  furnishes  to 
every  physician,  student,  and  lawyer  a  veritable  treasure-house  of  information. 

The  Practitioner,  London 

"  The  illustrations  appear  to  be  the  best  that  have  ever  been  published  in  connection  with 
this  department  of  medicine,  and  they  cannot  fail  to  be  useful  alike  to  the  medical  jurist  and  to 
the  student  of  forensic  medicine." 

Chapman's 
Medical  Jurisprudence 

Medical  Jurisprudence,  Insanity,  and  Toxicology.  By  HENRY  C. 
CHAPMAN,  M.  D.,  Professor  of  Institutes  of  Medicine  and  Medical 
Jurisprudence  in  Jefferson  Medical  College,  Philadelphia.  Handsome 
I2mo  of  329  pages,  fully  illustrated.  Cloth,  $1.75  net. 

RECENTLY  ISSUED— THIRD   REVISED   EDITION,  ENLARGED 

This  work  is  based  on  the  author's  practical  experience  as  coroner's  physician 
of  the  city  of  Philadelphia  for  a  period  of  six  years.  Dr.  Chapman's  book, 
therefore,  is  of  unusual  value. 

This  third  edition  has  been  thoroughly  revised  and  greatly  enlarged,  so  as  to 
bring  it  absolutely  in  accord  with  the  very  latest  advances  in  this  important  branch 
of  medical  science.  There  is  no  doubt  it  will  meet  with  as  great  favor  as  the 
previous  editions. 

Medical  Record,  New  York 

"The  manual  is  essentially  practical,  and  is  a  useful  guide  for  the  general  practitioner, 
besides  possessing  literary  merit." 


NURSING.  1 1 


Golebiewski  anv  Bailey's 
Accident  Diseases 


Atlas  and  Epitome  of  Diseases  Caused  by  Accidents.     By  DR.  ED. 

GOLEBIEWSKI,  of  Berlin.  Edited,  with  additions,  by  PEARCE  BAILEY, 
M.D.,  Consulting  Neurologist  to  St.  Luke's  Hospital,  New  York. 
With  71  colored  illustrations  on  40  plates,  143  text-illustrations,  and 
549  pages  of  text.  Cloth,  $4.00  net.  In  Saunders'  Hand- Atlas 
Series. 

This  work  contains  a  full  and  scientific  treatment  of  the  subject  of  accident 
injury  ;  the  functional  disability  caused  thereby  ;  the  medicolegal  questions  in- 
volved, and  the  amount  of  indemnity  justified  in  given  cases.  The  work  is 
indispensable  to  every  physician  who  sees  cases  of  injury  due  to  accidents,  to 
advanced  students,  to  surgeons,  and,  on  account  of  its  illustrations  and  statistical 
data,  it  is  none  the  less  useful  to  accident-insurance  organizations. 

The  Medical  Record,  New  York 

"  This  volume  is  upon  an  important  and  only  recently  systematized  subject,  which  is  grow- 
iag  in  extent  all  the  time.  The  pictorial  part  of  the  book  is  very  satisfactory." 

Stoney's 
Materia  Medica  for  Nurses 

Practical  Materia  Medica  for  Nurses,  with  an  Appendix  containing 
Poisons  and  their  Antidotes,  with  Poison-Emergencies  ;  Mineral  Waters  ; 
Weights  and  Measures ;  Dose-List,  and  a  Glossary  of  the  Terms  used 
in  Materia  Medica  and  Therapeutics.  By  EMILY  M.  A.  STONEY,  of  the 
Carney  Hospital,  South  Boston.  I2mo  of  300 pages.  Cloth,  $1.50  net. 

RECENTLY  ISSUED-NEW  (3rd)  EDITION 

In  making  the  revision  for  this  new  third  edition,  all  the  newer  drugs  have 
been  introduced  and  fully  discussed.  The  consideration  of  the  drugs  includes 
their  sources  and  composition,  their  various  preparations,  physiologic  actions, 
directions  for  administering,  and  the  symptoms  and  treatment  of  poisoning. 

Journal  of  the  American  Medical  Association 

"  So  far  as  we  can  see,  it  contains  everything  that  a  nurse  ought  to  know  in  regard  to  drugs. 
As  a  reference-book  for  nurses  it  will  without  question  be  very  useful." 


12  SAUNDERS'    BOOKS    6>A 


Stoney's  Nursing 


Practical  Points  in  Nursing:  for  Nurses  in  Private  Practice.  By 
EMILY  M.  A.  STONEY,  Superintendent  of  the  Training  School  for  Nurses 
at  the  Carney  Hospital,  South  Boston,  Mass.  466  pages,  fully  illus- 
trated. Cloth,  $1.75  net. 

THIRD   EDITION.  THOROUGHLY  REVISED— RECENTLY   ISSUED 

In  this  volume  the  author  explains  the  entire  range  of  private  nursing  as  dis- 
tinguished from  hospital  nursing,  and  the  nurse  is  instructed  how  best  to  meet  the 
various  emergencies  of  medical  and  surgical  cases  when  distant  from  medical  or 
surgical  aid  or  when  thrown  on  her  own  resources.  An  especially  valuable  feature 
will  be  found  in  the  directions  how  to  improvise  everything  ordinarily  needed  in  the 
sick-room. 

The  Lancet,  London 

"A  very  complete  exposition  of  practical  nursing  in  its  various  branches,  including  obstetric 
and  gynecologic  nursing.     The  instructions  given  are  full  of  useful  detail." 


Stoney's  Technic  for  Nurses 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  EMILY  M.  A. 
STONEY,  Superintendent  at  Carney  Hospital,  South  Boston.  Revised 
by  FREDERIC  R.  GRIFFITH,  M.  D.,  Surgeon,  of  New  York.  i2tno, 
278  pages,  illustrated.  Cloth,  $1.50  net. 

RECENTLY  ISSUED— NEW  (ad)  EDITION 
Trained  Nurse  and  Hospital  Review 

"  These  subjects  are  treated  most  accurately  and  up  to  date,  without  the  superfluous  reading 
which  is  so  often  employed.  .  .  .  Nurses  will  find  this  book  of  the  greatest  value  both  during 
their  hospital  course  and  in  private  practice." 

Spratling  on  Epilepsy 

Epilepsy  and  Its  Treatment.  By  WILLIAM  P.  SPRATLING,  M.  D., 
Medical  Superintendent  of  the  Craig  Colony  for  Epileptics,  Sonyea, 
New  York.  Octavo  of  522  pages,  fully  illustrated.  Cloth,  #4.00  net. 

The  Lancet,  London 

"  Dr.  Spratling's  work  is  written  throughout  in  a  clear  and  readable  style.  .  .  .  The  work 
is  a  mine  of  information  on  the  whole  subject  of  epilepsy  and  its  treatment." 


CHILDREN  AND   HYGIENE.  13 

Griffith's  Care  of  the  Baby 

The  Care  of  the  Baby.  By  J.  P.  CROEER  GRIFFITH,  M.  D.,  Clinical 
Professor  of  Diseases  of  Children,  University  of  Penn. ;  Physician  to  the 
Children's  Hospital,  Phila.  I2mo,  455  pp.  Illustrated.  Cloth,  $1.50  net. 

JUST  ISSUED— THE  NEW  (4th)  EDITION 

The  author  has  endeavored  to  furnish  a  reliable  guide  for  mothers.  He  has 
made  his  statements  plain  and  easily  understood,  in  the  hope  that  the  volume 
may  be  of  service  not  only  to  mothers  and  nurses,  but  also  to  students  and  practi- 
tioners whose  opportunities  for  observing  children  have  been  limited. 

New  York  Medical  Journal 

"We  are  confident  if  this  little  work  could  find  its  way  into  the  hands  of  every  trained 
nurse  and  of  every  mother,  infant  mortality  would  be  lessened  by  at  least  fifty  per  cent." 

Crothers*  Morphinism 

Morphinism  and  Narcomania  from  Opium,  Cocain,  Ether,  Chloral, 
Chloroform,  and  other  Narcotic  Drugs ;  also  the  Etiology,  Treatment, 
and  Medicolegal  Relations.  ByT.  D.  CROTHERS,  M.  D.,  Superintendent 
of  Walnut  Lodge  Hospital,  Hartford,  Conn.  .Handsome  I2mo  of  351 
pages.  Cloth,  $2.00  net. 

The  Lancet,  London 

"An  excellent  account  of  the  various  causes,  symptoms,  and  stages  of  morphinism,  the 
discussion  being  throughout  illuminated  by  an  abundance  of  facts  of  clinical,  psychological,  and 
social  interest." 

Abbott's  Transmissible  Diseases 

The  Hygiene  of  Transmissible  Diseases :  Their  Causation,  Modes 
of  Dissemination,  and  Methods  of  Prevention.  By  A.  C.  ABBOTT,  M.  D., 
Professor  of  Hygiene  and  Bacteriology,  University  of  Pennsylvania. 
Octavo,  351  pages,  with  numerous  illustrations.  Cloth,  $2.50  net. 

SECOND   REVISED    EDITION 

During  the  interval  that  has  elapsed  since  the  appearance  of  the  first  edition 
investigations  upon  the  modes  of  dissemination  of  certain  of  the  specific  infections 
have  been  very  active.  The  sections  on  Malaria,  Yellow  Fever,  Plague,  Filariasis, 
Dysentery,  and  Tuberculosis  have  been  both  revised  and  enlarged. 

The  Lancet,  London 

"  We  heartily  command  the  book  as  a  concise  and  trustworthy  guide  in  the  subject  w««*i 
which  it  deals,  and  we  sincerely  congratulate  Professor  Abbott." 


I4  SAUNDERS    BOOKS    ON 

Register's  Fever  Nursing  just  issued 

A  TEXT- BOOK.  ON  PRACTICAL  FEVER  NURSING.  By  EDWARD  C. 
REGISTER,  M.D.,  Professor  of  the  Practice  of  Medicine  in  the  North 
Carolina  Medical  College.  Octavo  of  350  pages. 

The  work  completely  covers  the  field  of  practical  fever  nursing..  Just  sufficient  of 
pathology,  symptoms,  and  treatment  is  given  to  enable  the  nurse  to  care  for  the  patient 
intelligently.  The  work  is  thoroughly  practical  and  nurses  will  find  it  most  valuable. 
The  illustrations  show  the  nurse  how  to  perform  those  measures  that  come  within  her 
province;  such  as  bathing,  hypodermoclysis,  pulse  and  temperature  taking,  etc. 

Hecker,  Trumpp,  and  Abt  on  Children  just  Ready 

ATLAS  AND  EPITOME  OK  DISEASES  OF  CHILDREN.  By  Dr.  R.  link  IK 
and  Dr.  J.  TRUMPP,  of  Munich.  Edited,  with  additions,  by  ISAAC  A. 
ABT,  M.D.,  Assistant  Professor  of  Diseases  of  Children,  Rush  Medical 
College,  Chicago.  With  48  colored  plates,  144  text-cuts,  and  453  pages 
of  text.  Cloth,  $5. oo -net. 

The  many  excellent  lithographic  plates  represent  cases  seen  in  the  authors'  clinics,  and 
have  been  selected  with  great  care,  keeping  constantly  in  mind  the  practical  needs  of  the 
general  practitioner.  These  beautiful  pictures  are  so  true  to  nature  that  their  study  is 
equivalent  to  actual  clinical  observation.  The  editor,  Dr.  Isaac  A.  Abt,  has  added  all  new 
methods  of  treatment. 

Lewis'  Anatomy  and  Physiology  Recently  issued 

ANATOMY  AND  PHYSIOLOGY  FOR  NURSES.  By  LERov  LEWIS,  M.D., 
Surgeon  to  and  Lecturer  on  Anatomy  and  Physiology  for  Nurses  at  the 
Lewis  Hospital,  Bay  City,  Michigan.  iamo  of  317  pages,  with  146 
illustrations.  Cloth,  $1.75  net. 

A  demand  for  such  a  work  as  this,  treating  the  subjects  from  the  nurses'  point  of  view, 
has  long  existed.  Dr.  Lewis  has  based  the  plan  and  scope  of  this  work  on  the  methods 
employed  by  him  in  teaching  these  branches,  making  the  text  unusually  simple  and  clear. 

The  Nurses  Journal  of  the  Pacific  Coast 

"  It  is  not  in  any  sense  rudimentary,  but  comprehensive  in  its  treatment  of  the  subjects 
in  hand.  The  application  of  the  knowledge  of  anatomy  in  the  care  of  the  patient  is 
emphasized." 

Friedenwald  and  Ruhrah's  Dietetics  Recently  issued 

DIETETICS  FOR  NURSES.  By  JULIUS  FRIEDENWALD,  M.D.,  Clinical 
Professor  of  Diseases  of  the  Stomach,  and  JOHN  RUHRAH,  M.D.,  Clinical 
Professor  of  Diseases  of  Children,  College  of  Physicians  and  Surgeons, 
Baltimore,  izmo  volume  of  365  pages.  Cloth,  $1.50  net. 

This  work  has  been  prepared  to  meet  the  needs  of  the  nurse,  both  in  the  training 
school  and  after  graduation.  It  aims  to  give  the  essentials  of  dietetics,  considering  briefly 
the  physiology  of  digestion  and  the  various  classes  of  foods  and  the  part  they  play  in 
nutrition. 

American  Journal  of  Nursing 

"  It  is  exactly  the  book  for  which  nurses  and  others  have  long  and  vainly  sought.  A 
simple  manual  of  dietetics,  which  does  not  turn  into  a  cook-book  at  the  end  of  the  first 
or  second  chapter. 


NURSING  AND  CHILDREN.  15 

Paill'S    Fever    Nursing  Recently  Issued 

NURSING  IN  THE  ACUTE  INFECTIOUS  FEVERS.  By  GEORGE  P.  PAUL, 
M.D.,  Assistant  Visiting  Physician  to  the  Samaritan  Hospital,  Troy,  N.  Y. 
i2mo  of  200  pages.  Cloth,  $1.00  net. 

Dr.  Paul  has  taken  great  pains  in  the  presentation  of  the  care  and  management  of  each 
fever.  The  book  treats  of  fevers  in  general,  then  each  fever  is  discussed  individually,  and 
the  latter  part  of  the  book  deals  with  practical  procedures  and  valuable  information. 

The  London  Lancet 

"The  book  is  an  excellent  one  and  will  be  of  value  to  those  for  whom  it  is  intended. 
It  is  well  arranged,  the  text  is  clear  and  full,  and  the  illustrations  are  good." 

Paul's  Materia  Medica  for  Nurses  just  issued 

MATERIA  MEDICA  FOR  NURSES.  By  GEORGE  P.  PAUL,  M.D.,  Assistant 
Visiting  Physician  to  the  Samaritan  Hospital,  Troy.  12010  of  240 
pages.  Cloth,  $1.50  net. 

Dr.  Paul  arranges  the  physiologic  actions  of  the  drugs  according  to  the  action  of  the 
drug  and  not  the  organ  acted  upon.  An  important  section  is  that  on  pretoxic  signs, 
giving  the  warnings  of  the  full  action  or  the  beginning  toxic  effects  of  the  drug,  which, 
if  heeded,  may  prevent  many  cases  of  drug  poisoning.  The  nurse  should  know  these 
signs. 


Pyle's  Personal  Hygiene  The  New 

A  MANUAL  OF  PERSONAL  HYGIENE:  Proper  Living  upon  a  Physiologic 
Basis.  By  Eminent  Specialists.  Edited  by  WALTER  L.  PYLE,  A.M., 
M.D.,  Assistant  Surgeon  to  Wills  Eye  Hospital,  Philadelphia.  Octavo 
volume  of  451  pages,  fully  illustrated.  Cloth,  $1.50  net. 

To  this  new  edition  there  have  been  added,  and  fully  illustrated,  chapters  on  Domestic 
Hygiene    and    Home  Gymnastics,  besides  an  appendix  containing  methods  of  Hydro- 
therapy,   Mechanotherapy,  and   First  Aid   Measures.     There  is  also  a  Glossary  of  the 
medical  terms  used. 
Boston  Medical  and  Surgical  Journal 

"  The  work  has  been  excellently  done,  there  is  no  undue  repetition,  and  the  writers 
have  succeeded  unusually  well  in  presenting  facts  of  practical  significance  based  on  sound 
knowledge." 


Galbraith's  Four  Epochs  of  Woman's  Life 

THE  FOUR  EPOCHS  OF  WOMAN'S  LIFE.  By  ANNA  M.  GALBRAITH, 
M.D.  With  an  Introductory  Note  by  JOHN  H.  MUSSER,  M.D.,  Univer- 
sity of  Pennsylvania.  i2mo  of  247  pages.  Cloth,  $1.50  net. 

Birmingham  Medical  Review 

"  We  do  not  as  a  rule  care  for  medical  books  written  for  the  instruction  of  the  public  ; 
but  we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is  in  the  main  wise  and  whok 


Starr  on  Children  second  Edition 

AMERICAN  TEXT-BOOK  OF  DISEASES  OF  CHILDREN.  Edited  by  Louis 
STARR,  M.D.,  assisted  by  THOMPSON  S.  WESTCOTT,  M.D.  Octavo,  1244 
pages,  illustrated.  Cloth,  $7.00  net;  Half  Morocco,  $8.50  net. 


1  6  SAUNDERS'   BOOKS  ON  CHILDREN. 

_..     ..  Fifth  Edition,  Revised 

American  Pocket  Dictionary  just  issued 

AMERICAN  POCKET  MEDICAL  DICTIONARY.  Edited  by  W.  A.  NEW- 
MAN BORLAND,  M.  D.,  Assistant  Obstetrician  to  the  Hospital  of  the 
University  of  Pennsylvania.  Containing  the  pronunciation  and  defini- 
tion of  the  principal  words  used  in  medicine  and  kindred  sciences,  with 
64  extensive  tables.  Handsomely  bound  in  flexible  leather,  with  gold 
edges,  $1.00  net;  with  patent  thumb  index,  $1.25  net. 

"  I  can  recommend  it  to  our  students  without  reserve."  —  J.  H.  HOLLAND,  M.  D.,  Dean 
of  tke  Jtftrson  Medical  Ctllffe,  Philadelphia. 

Morrow's  Immediate  Care  of  Injured  just  Ready 

IMMEDIATE  CARE  OF  THE  INJURED.  By  ALBERT  S.  MORROW,  M.  I)., 
Attending  Surgeon  to  the  New  York  City  Hospital  for  the  Aged  and 
Infirm.  Octavo  of  340  pages,  with  238  illustrations.  Cloth,  $2.50  net. 

Dr.  Morrow's  book  on  emergency  procedures  is  written  in  a  definite  and  decisive  style, 
the  reader  being  told  just  what  to  do  in  every  emergency.  It  is  a  practical  book  for  every 
day  use,  and  the  large  number  of  excellent  illustrat'ons  can  not  but  make  the  treatment  to 
be  pursued  in  any  case  clear  and  intelligible.  Physicians  and  nurses  will  find  it  indispensible. 


Powell's  Diseases  of  Children  Third  Edition, 

ESSENTIALS  OF  THE  DISEASES  OF  CHILDREN.  By  WILLIAM  M.  POWELL, 
M.  D.  Revised  by  ALFRED  HAND,  JR.,  A.  B.,  M.  D.,  Dispensary 
Physician  and  Pathologist  to  the  Children's  Hospital,  Philadelphia. 
i2mo  volume  of  259  pages.  Cloth,  $1.00  net.  In  Sounders' 
Question-  Compend  Series. 


Shaw  on  Nervous  Diseases  and  Insanity 

ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY:  Their  Symptoms 
and  Treatment.  A  Manual  for  Students  and  Practitioners.  By  the  late 
JOHN  C.  SHAW,  M.  D.,  Clinical  Professor  of  Diseases  of  the  Mind  and 
Nervous  System,  Long  Island  College  Hospital,  New  York.  i2mo  of 
204  pages,  illustrated.  Cloth,  #1.00  net.  In  Saunders1  Question-  Com- 
pend Series. 

"  Clearly  and  intelligently  written  ;  we  have  noted  few  inaccuracies  and  several  sug- 
gestive points.  Some  affections  unmentioned  in  many  of  the  large  text-books  are  noted." 
—  Boston  Medical  and  Surgical  Journal. 

Starr's  Diets  for  Infants  and  Children 

DIETS  FOR  INFANTS  AND  CHILDREN  IN  HEALTH  AND  IN  DISEASE.  By 
Louis  STARR,  M.  D.,  Consulting  Pediatrist  to  the  Maternity  Hospital, 
Philadelphia.  230  blanks  (pocket-book  size).  Bound  in  flexible  leather, 
$1.25  net. 

Grafstrom's  Mechano-Therapy  se^T^lT^n 

A  TEXT-BOOK  OF  MECHANO-THERAPY  (Massage  and  Medical  Gymnas- 
tics). By  AXEL  V.  GRAFSTROM,  B.  Sc.,  M.  D.,  Attending  Physician  to 
the  Gustavus  Adolphus  Orphange,  Jamestown,  New  York.  i2mo,  200 
pages,  illustrated.  Cloth,  $1.25  net. 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 

This  book  is  DUE  on  the  last  date  stamped  below. 


•one  mi  2  5  '8 


Form  L9-Series  4939 


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